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Functions of the noseFunctions of the nose
To smellTo smell
To filter, warm and humidify the air To filter, warm and humidify the air we breathewe breathe
Changes in TerminologyChanges in Terminology
““OLD”: Seasonal & PerennialOLD”: Seasonal & Perennial
““NEW”: Acute or Intermittent and NEW”: Acute or Intermittent and Chronic or Persistent (WHO 2000)Chronic or Persistent (WHO 2000)
The SymptomsThe Symptoms
Seasonal/Acute: Itching, Sneezing, Seasonal/Acute: Itching, Sneezing, Rhinorrhea.Rhinorrhea.
Perennial/Chronic: The blocked nosePerennial/Chronic: The blocked nose
The Acute SymptomsThe Acute Symptoms
The tingleThe tingle The itchy noseThe itchy nose The volley of sneezesThe volley of sneezes The flooding rhinorrheaThe flooding rhinorrhea The ocular symptomsThe ocular symptoms The itchy palateThe itchy palate
The Chronic SymptomsThe Chronic Symptoms
A blocked nose, often with hyposmia & A blocked nose, often with hyposmia & hypoguesiahypoguesia
Recurrent bouts of AOM in kidsRecurrent bouts of AOM in kids Otitis Media with effusion in kids and adultsOtitis Media with effusion in kids and adults The allergic saluteThe allergic salute Recurrent bouts of acute sinusitis in adultsRecurrent bouts of acute sinusitis in adults Chronic sinusitis and nasal polyposisChronic sinusitis and nasal polyposis A nasal voiceA nasal voice Snoring and OSA in kids and adultsSnoring and OSA in kids and adults
The Culprits: PollensThe Culprits: Pollens
In the In the Mauritian Mauritian context, a context, a frequently frequently accused accused innocent: innocent: the sugar the sugar cane pollencane pollen
The Allergic ReactionThe Allergic Reaction
An Idiot’s Guide to the chain of An Idiot’s Guide to the chain of reactions, from the first meeting to reactions, from the first meeting to the divorce!the divorce!
The first date -1The first date -1
ANTIGENS
MACROPHAGE
The macrophage ingests the allergens, breaks them up and presents some of their chemicals to the immune cells, the lymphocytes
The first date -2The first date -2
Lymphocyte Plasmocyte
Antibodies Mastocyte
The lymphocytes send a message to the plasmocytes, that produce the antibodies
The antibodies attach themselves firmly to the mastocytes(containing granules that intervene in the inflammatory reaction) and to basophils
The second date -1The second date -1
The antigens this time link up to the antibodies attached to the mastocyte, and the latter is then activated
The second date -2The second date -2
The activated mastocyte liberates its granules, that contain histamine and other inflammatory chemicals,(triptase, prostaglandins) responsible for the allergic reaction
The StartThe Start
ALLERGEN ImmunoglobulinE (IgE)Specially in the mastocytes
Inflammatory Mediators Cytokines
ALLERGICREACTION
The ProgressionThe Progression
Watery RhinorrheaPruritus
Sneezing++++
Immediate Reaction:Acute Inflammation
Vasodilatation,oedemaMucus++ Itching
HistamineLeukotrienes
Blocked noseSinusitis
PharyngitisOtitis
Late Reaction:Chronic Inflammation
Congested MucosaObstruction, Infection
Neutral proteases
Cytokines, Interleukins
Early Phase Late Phase
DiagnosisDiagnosis HISTORY: ALL IMPORTANTHISTORY: ALL IMPORTANT Simple Rhinoscopy: Pale, boggy, bluish Simple Rhinoscopy: Pale, boggy, bluish
mucous membranemucous membrane Sometimes PolypsSometimes Polyps Skin scratch tests and lab tests (RAST, Skin scratch tests and lab tests (RAST,
Phadiatop, Total IgE(inaccurate), nasal IgE, Phadiatop, Total IgE(inaccurate), nasal IgE, nasal mucus eosinophils)-test food nasal mucus eosinophils)-test food allergies in kidsallergies in kids
Imaging NOT necessary for simple ARImaging NOT necessary for simple AR
Differential DiagnosisDifferential Diagnosis Chronic Idiopathic Rhinitis (V.M.R)Chronic Idiopathic Rhinitis (V.M.R) NARESNARES Nasal hypersensitivity, specially to Nasal hypersensitivity, specially to
dust, perfume, tobacco dust, perfume, tobacco smoke,SO2,NO2, cold airsmoke,SO2,NO2, cold air
Drug induced- Aspirin (Widal’s), ACE Drug induced- Aspirin (Widal’s), ACE inhibitors, HRT, Methyl inhibitors, HRT, Methyl DOPA,ReserpineDOPA,Reserpine
Last trimester of pregnancyLast trimester of pregnancy
Treatment PrinciplesTreatment Principles
Acute/Intermittent/Seasonal Acute/Intermittent/Seasonal SymptomsSymptoms
Chronic/Persistent/Perennial Chronic/Persistent/Perennial SymptomsSymptoms
Allergen AvoidanceAllergen Avoidance
If the allergen has been identified:If the allergen has been identified: Avoid grass pollensAvoid grass pollens Get rid of offending petsGet rid of offending pets Treat pillows and mattressesTreat pillows and mattresses Avoid offending foodsAvoid offending foods
But, unfortunately, more often than But, unfortunately, more often than not, medication needednot, medication needed
Acute SymptomsAcute Symptoms
Local and Systemic decongestantsLocal and Systemic decongestants
22ndnd Generation Antihistamines, Generation Antihistamines, systemic and localsystemic and local
Local SteroidsLocal Steroids
Chronic SymptomsChronic Symptoms
Local and systemic steroidsLocal and systemic steroids
22ndnd Generation Antihistamines Generation Antihistamines
Other drugs/measuresOther drugs/measures
Other drugs/measuresOther drugs/measures Sodium CromoglycateSodium Cromoglycate Ipatropium Bromide (rhinorrhea)Ipatropium Bromide (rhinorrhea) SIT & SLITSIT & SLIT Leukotriene antagonists (Zafirlukast, Leukotriene antagonists (Zafirlukast,
Montelukast)Montelukast) Empirical dietary exclusion of cow’s Empirical dietary exclusion of cow’s
milk and food additives (benzoates, milk and food additives (benzoates, nitrites, sulphites, colourings)nitrites, sulphites, colourings)
Specific ImmunotherapySpecific Immunotherapy Sublingual or injectionSublingual or injection Should be reserved for mono/bi Should be reserved for mono/bi
allergens (e.g. grass pollen & house-allergens (e.g. grass pollen & house-dust mite)dust mite)
NOT as first line, but if other NOT as first line, but if other measures uselessmeasures useless
Injection method should only be done Injection method should only be done with resuscitative facilities available with resuscitative facilities available
Side-Effects -1Side-Effects -1 Early 2Early 2ndnd G. antiH: (Astemizole, G. antiH: (Astemizole,
Terfenadine..) : Liver and cardiac Terfenadine..) : Liver and cardiac problems when used in association problems when used in association with some other drugswith some other drugs
Newer ones (fexofenadine, cetirizine, Newer ones (fexofenadine, cetirizine, loratidine…):safe, but still cause loratidine…):safe, but still cause drowsynessdrowsyness
Local acting (levocabastine, Local acting (levocabastine, azelastine,): local irritation & azelastine,): local irritation & unpleasant tasteunpleasant taste
Side effects -2Side effects -2 Local decongestants – abuse & R.M.Local decongestants – abuse & R.M. Systemic decongestants – glaucoma, Systemic decongestants – glaucoma,
prostate, HBP, palpitations, insomniaprostate, HBP, palpitations, insomnia Local Steroids sprays – Great, but Local Steroids sprays – Great, but
local irritation, epistaxis & no effect local irritation, epistaxis & no effect on eye/palate itchon eye/palate itch
Cromoglycate – qds, hence poor Cromoglycate – qds, hence poor compliance compliance
Ipatropium – only on dripIpatropium – only on drip
Systemic Steroids??Systemic Steroids??
Very useful in treatment of infective Very useful in treatment of infective acute episodes (High Dose Short acute episodes (High Dose Short Term)Term)
BE VERY WARY OF THE DEPOT BE VERY WARY OF THE DEPOT STEROID INJECTIONS: Osteoporosis, STEROID INJECTIONS: Osteoporosis, muscle damage, diabetes, glaucoma, muscle damage, diabetes, glaucoma, cataracts, gastric ulcers…cataracts, gastric ulcers…
Some other helpful(?) measuresSome other helpful(?) measures
Saline douchesSaline douches Petroleum jelly (Vaseline) applicationPetroleum jelly (Vaseline) application InhalationsInhalations Anti-oxidants (Vit C, E, Beta Anti-oxidants (Vit C, E, Beta
carotene, zinc, selenium…)carotene, zinc, selenium…) ““Muco-regulators” (carbocisteine..)Muco-regulators” (carbocisteine..)
To summarise:To summarise: The problem with allergies such as The problem with allergies such as
Hay fever and Allergic Rhinitis is that Hay fever and Allergic Rhinitis is that it is considered to be a trivial and it is considered to be a trivial and inconsequential disease. Symptoms inconsequential disease. Symptoms such as runny nose, itchy eyes and such as runny nose, itchy eyes and nose with sneezing and blockage are nose with sneezing and blockage are obviously not life threatening, but obviously not life threatening, but affect up to 25% of the population affect up to 25% of the population and are the cause of significant and are the cause of significant disability and cost to society…/cont.disability and cost to society…/cont.
To summarise (cont)To summarise (cont)
Patients may also experience fatigue, Patients may also experience fatigue, irritability, as well as mood, cognitive and irritability, as well as mood, cognitive and sleep disturbance in addition to the nasal, sleep disturbance in addition to the nasal, ocular and throat symptoms. Allergic ocular and throat symptoms. Allergic rhinitis has important co-morbid rhinitis has important co-morbid associations such as chronic sinusitis, glue associations such as chronic sinusitis, glue ear, asthma exacerbations, nasal polyps, ear, asthma exacerbations, nasal polyps, sleep apnoea and dental malocclusionsleep apnoea and dental malocclusion..
Dr A Morris, January 2007, Surrey Allergy Dr A Morris, January 2007, Surrey Allergy ClinicClinic