Pathophysiology and Diagnostic Procedure in Allergic Rhinitis

8/17/2019 Pathophysiology and Diagnostic Procedure in Allergic Rhinitis

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Pathophysiology and Diagnostic Procedure in Allergic RhinitisBy :

Iwin Sumarman

Faculty of Medicine Padjadjaran ni!ersityDr" #asan Sadi$in %eneral #ospital

Bandung & Indonesia

Chronic ongoing disease Factors :- Environmental (allergenic and or nonallergenic) - Genetics- Immunity distrubances

- Suceptible to secunder infections Distribution of PAR (symptoms in IndonesiaSymptoms 1) 2) 3)

Stage 2+3+4 Stage 3+4Rhinorhea 9 !" ##!$ $!% &"!Snee'ing 9(!) #*!* (!" &)!&

+ Congestion &(!& *$!$ #%!* "#!* + Itching " !( %)!( nd nd,dapted from:

" Sumarman et al. /asan Sadi0in /osp. E+1-234 patients 56andung! "99%% Suprihati et al 7aryadi /osp. E+1-234 patients 5Semarang! "9 ** /aryanto 8 Sumarman. 53opulation of 6andung City! "999

,llergic Rhinitis

DIA%'(S)I* Procedure:

- History of Nasal & non nasal symptoms- /istory of Family ,llergy- +asal 8 +on nasal clinical signs- ,d unct diagnostic

1he potential treatment modalities of ,llergic Rhinitis management:1hree basic approach:

". ,llergen avoidance%. 3harmacotherapy


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*. Immunotherapy 5 /2 Initiative ,RI, %$$$2ptional therapy:

3harmacotherapy and;or surgery for complications Either diagnostic or managementof allergic rhinitis! present or future! needs a good understanding of allergic rhinitis phatophysiology

Pathophysiology of Allergic nflammation!hree phases "

Sensiti'ation phase Early 3hase ,llergic Reaction


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2ther important molecular products during Early- and C,=-" 5especially for E2S cells IC,=-" and E-selectin 5for E2S! 6aso and +eutro cells,dhesion molecules functions on recruitment of inflammatory cells :

1# $olling ( g s%perfammily and integrin)2# magination ( g s%perfammily and integrin)&. 4iapedesis 5


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,lergy RhinitisSymptoms:

, Rhinorrhea * Sneezing* Congestion * Nasal Itchy

1 tri'ial 2 mild 3 moderate 4 se'ereSnee-ing Predominantly in +PR

@ 5"-% minutes after allergen e?posure@ Is associated Aith mast cells degranulation:

@ /istamine stimmulation on H1 receptor on fi*re sensory ner'e ending@ Peptide endotelin 1@ ,e%-otrien

Pruritus- E?clusively in E3R- +asal itching and 3alatal clic0ing- /istamine stimm%lation on H1 receptor on fi*re

sensory ner'e ending- Protaglandin may also constri*%te

Rhinorrhea- ./cessi'e discharge from nasal m%co%s# mem*rane- 0egin 3 min# last for appro/# 2 to 3 min# after alergen challenge- Rhinorrhea B 5/istamine release from =ast cells


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- 3redominantly in E3R! can also in


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3ersistent : the symptoms are present:

@ H & days a Aee0 @ ,nd for more than & Aee0s +eA ,R symptoms grading classification 5according to /2 initiative ,RI, %$$$ :

=ild : that none of the folloAing items are present:@ Sleep disturbances@ Impairment of daily activity! leisure and;or sport@ Impairment of school or Aor0 @ 1rouble some symptoms

=oderate Severe :2ne or more of the folloAing items are present:

@ Sleep disturbances

@ Impairment of daily activity! leisure and;or sport@ Impairment of school or Aor0 @ 1rouble some symptoms

DIA%'(S)I* Procedure:Routine tests:.according to /#( initiati!e ARIA 01112

Allergy tests 9 S-in test and or9 Ser%m specific g.)

.ndoscopy9 rigid or 9 fle/i*le

+asal secretion 5cytology

+asal challenge 5 allergen lysin aspirin Radiology 5plain radiographs and or C1-scan

DIA%'(S)I* Procedure: (ptional tests:.according to /#( initiati!e ARIA01112

Nasal *iopsy Nasal s a* *acteriology Radiology =RI=ucociliary function +asal airAay assessment 2lfaction tests +itric o?ide meassurement

S $ i n ) e s t s@ Scratch test@ 3atch test@ Intracutan test@ S0in pric0 test


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@ S0in endpoint titration 5SE1

+ach test has own ad!antages and disad!antages and specific indicationS $ i n P r i c $ ) e s t- Indonesian : )es $ulit tusu$ .)es $ulit cung$it2- Simple! save! painless! and preferably- Single device 5good enough and cheap- =ultiple devices 5better but more e?pensive- >olar region- 1he pric0 be placed H * cm apart

@ Standardi'ed e?tract@ 1he best set: J ) allergen! but can more@ +o pric0 bleeding 5in appropriate result

@ ,ssesment: diam. Aheal and flare 5mm 5$! "K! %K! *K and &K@ False negative H positive

S0in endpoint titration 5SE1

@ Indications:@ If S31 negative I4 test SE1@ For determinining I1 allerg. starting dose

@ E?tract mite ":"$$L other ":%$ 5Standardi'ed e?tract@ 4ilution " : # 5=ite M"N":#$$L M#N*"%.#$$ 52ther ,lg: M"N":"$$L

M#N)%.#$$


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@ Opper hand region! be placed H # cm apart@ ,ssesment: diam. Aheal 5mm

Aheal $P N &mm Aheal "#P # mm 5+egative resp Aheal "#P H # mm 53ositive resp

SE1 interpretation1he endpoint is the ne?t stronger dilution Aith a H %mm larger Aheal positiveresponse$ minute Aheal : & mm"# minutes Aheal:M# M & M * M % M " 4ilution

+ormal response# # ( 9 mm

Endpoint is M *,bnormal response:

Flash responseL 3lateau responseL /ourglass response S0in endpoint titration 5SE11he ultimate ob ective of SE1 are:

". Safe initiate dose of immunotherapy 5I1%. 4ecrease of interval of in ection of I1*. Osefull at prae seasonally or co-seasonally I1&. Safe testing and treatment on patient Aith severe symptoms


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)he ad!antages and disad!antages of in !itro test Imunoglo3ulin + .Ig+2- 4oes not mediate the allergic alone- sensiti'ed to miscellaneous antigens 5not specific- IgE R,S1 5$! "K! %K! *K! &K- IgE modified R,S1 5$! "K! %K! *K! &K- Specific to one antigen;allergen- 6ut e?pensive

*('*4 SI('S :". ,llergic rhinitis is IgE mediated hypersensitivity!

starting by sensiti'ation phase! folloAed by E3R and

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Pathophysiology and Diagnostic Procedure in Allergic Rhinitis