The nasal passages are lined with a membrane that produces
mucus Mucus is one of the body's defense systems: Thin clear
liquid, traps small particles and bacteria The trapped bacteria
usually remain harmless in healthy individuals Even under normal
circumstances, this produces a cycle of congestion and decongestion
that occurs continuously throughout the day When one side of the
nose is congested, air passes through the open, or decongested,
side. The sides alternate between being wide open and being
narrowed
Slide 3
More than 50 million Americans suffer from allergies Sixth
leading chronic disease in U.S. 4.5 billion dollars in health care
costs annually 3.8 million days lost yearly (from work and
school)
Slide 4
People with perennial allergic rhinitis, may experience sleep
disorders and daytime fatigue. Often they attribute this to
medication, but studies suggest congestion may be the culprit in
these symptoms. Patients with seasonal allergies experience
hundreds of brief, subtle awakenings, called "microarousals", each
night. In such cases, people are not aware that they wake up, but
such events can cause fatigue the next day.
Slide 5
Children with severe allergies may have a higher risk for
behavioral problems than those without allergies There have been
reports that 30% to 45% of people with allergic rhinitis also
suffer from ear infections (otitis media) Chronic nasal obstruction
can affect a child's appearance. If a child can only breathe
through the mouth, this might lead to an elongated face and an
overbite from teeth coming in at an abnormal angle Chronic rhinitis
can cause headaches and also affect a child's sleep, concentration,
hearing, appetite, and growth
Slide 6
Increasing age, atopy, and high socioeconomic status Parental
history is also positively associated with development of allergic
rhinitis. A maternal history of allergy was significantly
associated with a diagnosis of rhinitis by age 6 years Other risk
factors include indoor and outdoor air pollution
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Rhinitis develops when congestion becomes severe or other
changes occur that irritate the nasal passage Patient must
experience at least two of the following symptoms for an hour or
more on most days: Runny nose Obstruction in the nasal passage
Nasal itching Sneezing These symptoms may occur as a result of
colds or environmental irritants, such as allergens, cigarette
smoke, chemicals, changes in temperature, stress, exercise, or
other factors
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When rhinitis lasts for a long period, it is most often caused
by allergies but can also be caused by structural problems or
chronic infections.
Slide 12
Aging Process Mucous membranes become dry with age Cartilage
supporting the nasal passages weakens, causing changes in airflow
Therapy: Avoid possible allergens and airborne irritants and keep
the nasal passages moist. Decongestants would not be
appropriate
Slide 13
Increased parasympathetic stimulation Overreaction to
irritants, cigarette smoke, air pollutants, strong odors, alcoholic
beverages, stress, and exposure to cold Gustatory rhinitis Not the
same as allergic reaction
Slide 14
Foreign Objects Blockage in young children is very often caused
by foreign objects If left in place, they may eventually cause
infection and nasal discharge, usually in one side of the nose,
which may be yellow or green and foul smelling (very)
Slide 15
One in five pregnant women will experience rhinitis symptoms (2
nd or 3 rd trimester) Hormonally induced Spontaneously resolves
within few weeks after delivery Limited therapeutic options
Slide 16
Medications and Illegal Drugs overuse of decongestant sprays
can, over time (three to five days), cause inflammation in the
nasal passages and worsen rhinitis, Rhinitis Medicamentosa Aspirin,
Ibuprofen, and Naproxen Oral contraceptives, hormone replacement
therapy, anti-anxiety agents, some antidepressants, and some blood
pressure medications, including beta-blockers and vasodilators
Sniffing cocaine damages nasal passages and can cause chronic
rhinitis
Slide 17
Patients demonstrate Allergic Rhinitis symptoms but without
other systemic manifestations Negative SPT and negative RAST
Diagnosis: Nasal provocation and detection of specific IgE in nasal
mucosa
Polyps soft, fluid-filled sacs impede mucus drainage and
restrict airflow develop from sinus infections, do not regress on
their own and may multiply and cause considerable obstruction
Deviated Septum A common structural abnormality that causes
rhinitis When deviated, it is not straight but shifted to one side,
usually the left
Slide 20
Protrude from the sinuses into the nasal cavities, usually from
the middle meatus Can be unilateral, or bilateral Anosmia, most
common presentation Very common in CF 50% of children (4-16 y/o) w/
nasal polyps have CF
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Routinely ask for symptoms suggestive of asthma Perform chest
examination Consider lung function testing Consider tests for
bronchial hyperresponsiveness in selected cases
Slide 24
Moderate- severe one 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 AR
Classification in untreated patients
Slide 25
Diagnosis is clinical Allergy Testing Skin testing and in-vitro
blood testing Testing is important to institute specific avoidance
measures Skin testing is slightly more sensitive Common allergens
Outdoors: tree, grass, weed pollens, and mold Indoors: dust mites,
pet dander, cockroaches and mold
Immunoassay Not influenced by medication Not influenced by skin
disease Does not require expertise Quality control possible
Expensive Skin test Higher sensitivity Immediate results Requires
expertise Cheaper Immunoassay vs skin test for diagnosis of
allergy
Slide 29
Imaging studies X-rays have a limited value CT scans are
preferred for evaluation of sinusitis Endoscopy Usually performed
by an ENT physician, allows easy evaluation of the nose, and throat
areas
Slide 30
The management of allergic rhinitis involves the following
components: Allergen avoidance Pharmacotherapy. Allergen
immunotherapy. Of note, immunotherapy helps prevent the development
of asthma in children with allergic rhinitis, and thus should be
given special consideration in the pediatric population.
Slide 31
The most logical strategy for disease that relates to the
indoor environment Effectiveness requires comprehensive and
multifaceted measures More studies are needed to also address the
role of indoor pollutants (e.g. NO 2, tobacco smoke, )
Slide 32
Pets: If patient is allergic to pets, they should be given away
or kept outside If this isn't possible, they should at least be
confined to carpet- free areas outside the bedroom Cats harbor
significant allergens, which can even be carried on clothing; dogs
usually present fewer problems Washing animals once a week can
reduce allergens. Dry shampoos, such as Allerpet, are now available
for pets that remove allergens from skin and fur and are easier to
administer than wet shampoos.
Slide 33
Dust Control simply using a spray furniture polish is very
effective for reducing both dust and allergens Air cleaners,
filters for air conditioners, and vacuum cleaners with HEPA filters
can help remove particles and small allergens found indoors Neither
vacuuming nor the use of anti-mite carpet shampoo, however, is
effective in removing mites in house dust. In fact, vacuuming stirs
up both mites and cat allergens Carpets and rugs should be avoided
if possible
Slide 34
Bedding and Curtains Using semipermeable coverings to fully
encase mattresses, and pillows is the most proven effective step in
reducing dust mite levels Curtains should be replaced with shades
or blinds Bedding should be washed using the highest temperature
setting
Slide 35
Reducing Humidity in the House Dust mites thrive in humidity
and damp houses increase the risk for mold On-going humidifiers,
then, can be counterproductive. If they are used, humidity levels
should not exceed 40% and they should be cleaned daily with a
vinegar solution
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The newer second-generation antihistamines do not usually cause
drowsiness to the extent that the first generation antihistamines
do. Brand Names. Loratadine is approved for children age two and
over. Cetirizine is the only antihistamine to date approved for
infants as young as six months. Fexofenadine (Allegra) Studies
suggest that cetirizine is more effective than either of these
other agents in improving symptoms, including in children, although
cetirizine causes more drowsiness at higher doses.
Slide 39
Oral decongestants come in many brands, which mainly differ in
their ingredients. The most common active ingredient is
pseudoephedrine.
Slide 40
Side Effects of Decongestants Agitation and nervousness.
Drowsiness (particularly with oral decongestants and in combination
with alcohol). Changes in heart rate and blood pressure. Avoid
combinations of oral decongestants with alcohol or sedatives.
Slide 41
Nasal corticosteroids reduction of symptoms and exacerbations
reduction of mucosal inflammation reduction of late phase reactions
priming nasal hyperresponsiveness 1 reduction of mucosal mast cells
reduction of acute allergic reactions 2 suppression of glandular
activity and vascular leakage induction of vasoconstriction 3
Slide 42
Benefits: The most effective agents currently available for
treating allergic rhinitis. Blocks the inflammatory response that
triggers an allergic attack. They do not relieve symptoms
immediately but may take several hours before their effects are
felt. They reduce inflammation and mucus production. They improve
night sleep and daytime alertness in patients with perennial
allergic rhinitis. Beneficial in treating polyps in the nasal
passages.
Slide 43
Nasal corticosteroids Overall safe to use Adverse Effects Nasal
irritation Epistaxis Septal perforation (extremely rare) HPA axis
suppression (inconsistent and not clinically significant)
Suppressed growth (only in one study with beclomethasone)
Slide 44
Corticosteroids available in nasal spray form include the
following: Beclometazone (Beconaze). Approved for children over six
Mometasone furoate (Nasonex). Approved for use in patients as young
as three. Fluticasone (Flonase). Approved for children over four.
Budesonide (Rhinocort). Approved for children over six.
Efficacious and equal to or superior to oral antihistamines for
treatment of SAR Clinically significant effect on nasal congestion
Improved nasal symptoms in patients who failed oral antihistamines
Onset of action: 30 vs. 60-180 minutes for oral antihistamine Side
effects: Sedation, bitter taste
Anti-leukotriene treatment in allergic rhinitis Efficacy
Equipotent to H1 receptor antagonists but with onset of action
after 2 days Reduce nasal and systemic eosinophilia May be used for
simultaneous treatment of allergic rhinitis and asthma Safety
Dyspepsia (approx. 2%)
Slide 51
Criteria for Allergen Immunotherapy Severity of rhinitis
symptoms Duration of rhinitis symptoms Progression of rhinitis
Failure to respond to medical treatment
Slide 52
Administering Therapy Immunotherapy requires a prolonged course
of weekly injections ("allergy shots"). The process generally
follows this course: Injections of diluted extracts of the allergen
are given on a regular schedule, usually weekly at first, then in
increasing doses until a maintenance dose has been reached. It
usually takes several months to reach a maintenance dose. At that
time, intervals between shots can be two to four weeks, and the
treatment is continued for up to three to five years. Patients can
experience some relief within three to six months; if there is no
benefit within 18-24 months, the shots should be discontinued.
Slide 53
Not licensed to treat allergic rhinitis Could be considered in
severe cases unresponsive to conventional treatment Could be an
adjunct to immunotherapy in severe cases
Slide 54
>4 years should be treated as for adults Children (>4)
with AR and Asthma can be treated with combination of newer topical
and inhaled corticosteroids Diagnosis in smaller children is
difficult as can have up to 6 to 8 colds per year Small children
oral antihistamines, saline sprays and corticosteroids if symptoms
severe