allergic rhinitis.
#1 definition of rhinitis.
One or more of the following symptoms. - Nasal congestion
- Rhinorrhea (anterior or posterior)
- sneezing and
- Pruritus
- May have associated allergic conjunctivitis
#2 differential diagnosis based in etiology - Allergic rhinitis (IgE mediated rhinitis)
- perineal with seasonal exacerbation
- Perineal without seasonal exacerbation
- Episodic allergic rhinitis
- All of these symptoms can be mild/intermittent versus serious/debilitating
- Nonallergic rhinitis syndrome (Non IgE mediated rhinitis)
- Infectious rhinitis
- Vasomotor or idiopathic rhinitis
- Non-allergies rhinitis with eosinophilic syndrome (NARES)
- hormonal rhinitis
- Pregnancy associated ( between 2 months of pregnancy and 2 weeks postpartum)
- menstrual cycle associated rhinitis
- Drug-related rhinitis ( ACE inhibitor, aspirin/NSAIDs, phosphodiesterase 5 inhibitor, alpha receptor antagonist or decongestants)
- Atrophic rhinitis
- Mixed rhinitis
#3 pathophysiology of allergic rhinitis - IgE mediated. 2 phases of present has below. Symptoms similar in both phases, however, congestion predominates in late phase - Early phase response
- late phase response
IgE dependent process can also be grouped into following - seasonal allergies
- seasonal allergen like pollens are the common cause
- Perineal allergies
- perinatal allergen like the following are the common cause
- dust, mites, molds, animal allergen
- occupational allergen
- Perineal pollens
#5 testing - Skin testing for IgE antibody
- preferred method
- Based on history, environment patient lives in, living situation, occupation, activities etc. the type of allergen tested would be decided.
- in vitro testing for a specific IgE antibody
- 70-75% sensitive compared to the skin testing
#6 treatment options include the following
- Oral antihistamines
- Intranasal antihistamines
- Oral decongestants
- topical decongestants
- oral steroid
- Intranasal steroid
- intranasal Chromylyn
- Intranasal anti-cholinergic
- Oral leukotriene receptor antagonist
- nasal saline
- anti-IgE - omalizumab - only inpatient with asthma and allergic rhinitis
- Allergen immunotherapy
- Surgery
ALLERGIC RHINITIS (AR)- Diagnosis: Often Clinical (Characteristic symptoms, and a good response to emperic treatment with anti-histamines or nasal corticosteroids)
Formal diagnosis is based on evidence of sensitization, measured either by the presence of allergen-specific IgE in the serum or by positive epicutaneous skin tests (i.e., wheal and flare responses to allergen extracts) and a history of symptoms that correspond with exposure to the sensitizing allergen. It is easier to diagnose the disease when seasonal symptoms are present or when the pa- tient can clearly identify a single trigger than when symptoms are chronic or the patient reports more than one trigger, including allergens and irritants. Epicutaneous skin testing and test- ing for allergen-specific IgE have similar sensitivity, although they do not identify sensitization in an entirely overlapping group of patients.20 NEJM 2015
- Definite Severity:
- Moderate to Severe (presence of one or more of the following):
- Sleep Disturbance
- Impairment of Usual activities or exercise
- Impairment of School or Work Performance
- Troublesome Symptoms
- Differential Diagnosis:
- Non-allergic (noninflammatory) rhinopathy aka Vasomotor Rhinitis
- NAR is about 50% of all cases of Rhinitis
- Negative Serum IgE and Skin Testing (50 % of these patient have local nasal allergic rhinitis limited to nasal mucosa)
- Non-allergic Chronic Rhinosinusitis
- Mixed Rhinitis (Allergic Rhinitis + nonallergic Rhinitis)
- NAR in these cases could be a state of nasal hyper responsiveness due to AR
- Viral Infection (AVRS)
- Also causes seasonal symptoms
- Rhinovirus (Peaks in September, and smaller peak in the spring)
- Bacterial Infection (ABRS)
- Others
- Rhinitis medicamentosa: Rebound congestion especially with topical decongestants
- Treatment
- Episodic Symptoms: Oral/Nasal H1-Antihistamine ± PRN Oral/Nasal Decongestants
- Mild Symptoms (Seasonal or perennial):
- Intranasal Steroids OR
- Oral/Nasal H1-Antihistamine OR
- LTR Antagonist (Eg.Monteleucast)
- Moderate to Severe Symptoms:
- Intranasal Steroids OR
- Intranasal Steroids PLUS Nasal H1-Antihistamine OR
- Allergen Immunotherapy(SC or SL)
AOM
When to refer to ENT
Rhino-Sinusitis (RS)Acute (<4 weeks)
Subacute (4-12 weeks)
Chronic (>12 weeks)
Recurrent (2-4 or more episodes / yr with symptoms resolution in between) BMJ 2012
Acute RS (<4 weeks duration)
- Acute Bacterial RS: (<2 % of ARS) Abx (augmentin, or doxy) and Adjunctive Treatment
- Community acquired ABRS
- Nosocomial acquired ABRS
- Etiology
- 2.7% for S. pneumoniae,
- 31.6% for H. influenzae,
- 10.1% for S. aureus,
- 8.8% for M. catarrhalis
- References
- Acute Viral RS: Adjunctive Treatment
- rhinovirus, influenza virus, parainfluenza virus
- Adjunctive Treatment
- Analgesics: NSAIDS or Acetaminophen okay
- Topical Glucocroticoids (momentasone 200 or 400 mcg) most beneficia in Allergic RS, and other MILD RS (debatable)
- Topical Decongestants (oxymetazoline nasal; note also comes in opthal soln): used in AVRS not ABRS; efficacy controversial; use 3 or less days for concern of rebounds
- Oral Decongestants (ephedrine 25 mg, psedoephedrine 60 mg, phenylephrine 10 mg, phenylpropanolamine 25 mg): No use in ABRS; Controversial efficacy in AVRS; used for 3-5 days if associated Eustachian Tube Dysfunction in AVRS; Careful in Heart Ds, HTN, BPH
- Anti-histamines: Although frequently prescribed not recommended
- Mucolytis: Although frequently prescribed no studies published to support its use
- Acute Fungal RS (Mucor, Rhizopus, Aspergillus, Absidia, Basidiobolus)
- When to do Urgent Eval
- When suspecting complications of Sinusitis like extension to orbits or to brain
- High Fever and Severe Headache (abscess, meningitis)
- Abnormal Vision
- Periorbital Edema
- Altered Mental Status
CHRONIC RHINO-SINUSITIS (CRS):4 main Clinical Features of CRS are BMJ 2012
- Nasal blockage/obstruction/Nasal congestion
- Anterior/posterior rhinorrhoea
- Facial pain/pressure/fullness
- Anosmia (total/partial)
Other minor sx.
- Ear pain/pressure
- Dizziness
- Halitosis
- Dental pain
- Cough
- Drowsiness/malaise
- Sleep disturbance
- Fever
3 Red flag symptoms
- Unilateral symptoms
- Blockage
- Bleeding/bloodstained discharge
- Cacosmia
- Proptosis
- Diplopia
- Epiphora
- Neurological symptoms
Sub-Types
- CRS with NP
- CRS without NP
- With eosinophilic inflammatory features
- With other inflammatory features
- Vasomotor Rhinitis
- Non-allergic Rhinitis
- GERD
- Sarcoidosis
- Allergic Fungal RS (AFRS)
- Will have eosinophilic inflammation with presence of fungal hyphae (and positive skin tests)
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