Allergic Rhinitis

1

Department of PediatricsUniversity of North Sumatera Medical Faculty

H. Adam Malik Hospital

“THE ALLERGIC MARCH”

2

BMJ 2002

Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induce by an IgE-mediated inflamation after allergen exposure of the membrane of the nose

3

The new classification of allergic rhinitis:• Uses symptoms and quality of life parameters• Is based on duration: intermitten or persistent• Is base on severity: mild or moderate-severe

Classification of allergic rhinitis

Intermittent

Symptoms

• <4 days per week

• Or<4 weeks

Persistent

Symptoms

• >4 days/ week

• and > 4 weeks

Moderate- Severe

4

Mild

•Normal sleep

•Normal daily actvities,

sport, leisure

•Normal work and school

•No troublesome sympoms

Moderate- Severe

One or more items

•Abnormal sleep

• Impairment of daily activites,

sport, leisure

•Problems caused at work or scholl

•Troublesome symptoms

Allergic Rhinitis

• Seasonal allergic rhinitis/Hay fever :symptom complex that follows sensitization to windborne pollens of trees, grasses, and weeds.

5

• Perennial allergic rhinitis : the patient has year-round symptoms, caused generally by allergens which exposed with the patient. Most often by indoor inhalant allergens.

The mediator in allergic rhinitis

MEDIATORSSneezing

Histamine

Nasal itch

Histamine

Nasal blockage

LTC4,LTD4,PGD2,PGI2

Kinins

Histamin

Rhinorrhoea

Histamine

6

Basophil Mast cell Eosinophil

MEDIATORS HistamineHistamine

LTC4,LTD4

Pathogenesis

• Manifestasi alergi pada hidung lebih sering dibanding organ lain

• The important mediator : histamin• After histamin release, follow by leukotrien (LTB4, LTC4), PGD2 dan PAF (platelet

7

(LTB4, LTC4), PGD2 dan PAF (platelet activating faktor) � vasodilatation and vascular permeability

• Other mediator : sitokin• 50% hypersensitivity reaction type I, late phase (manifestation 4-6 hr after exposure)

The pathogenesis in allergic rhinitis

Allergen APCAPC

Th2 cellTh2 cell

EosinophilMast cellBasophil

B cell

Chemoattractants

IgE Cytokines Cytokines

8

Mediator/Cytokines

NervesVasodilatation

EdemaMucus

CHRONIC INFLAMATION

Etiology • Weather changes• Food• Dust• House mite, tick• Pollution• Scent of alcohol

9

• Scent of alcohol• Chemical scent :ink, paint

• Detergent ,powder• Pollen• Animal fur� Iritan non spesifik

Diagnosis / clinical manifestations

• Atopy history, Allergic salute, Allergic crease, Dennie`s line, Allergic shiner, Allergic face� No one`s phatognomonic

• Clinical manifestatio : > 4-5 yo � by age

10

• Paroxysmal sneezing• Rhinorrhea • Nasal obstrucion• Headache / lethargic

• Itching of the nose, palate, pharynx, & ears

• Itching, redness tearing of the eyes (conjunctive erythema)

Diagnosis / clinical manifestations………….

• The nasal mucous membranes are bluish, pale

• Clear mucoid nasal discharge, may become purulent (with secondary infection)

• Mannerisms (due to the itching nose /

11

• Mannerisms (due to the itching nose / attempts to improve the airway)

• Mouth breathing• Fever (unusual)

Diagnosis / clinical manifestations…………

• SPT � < 3 yo (?)• In vitrro (ELISA, RAST) � sensitivity (-), expensive

• Total IgE • Eosinofil (nasal secret)

12

• Eosinofil (nasal secret)

13

Treatment

• General : avoidance of exposure to suspected allergens/ irritants, environment control

• Immunotheraphy (if cannot avoid the inhalant allergens)

14

inhalant allergens)• Medicamentosa :

–Antihistamines (AH-1 oral, AH-1 lokal)– Pseudoephedrine (nasal obstruction)

•2-5 years : 15 mg / 6 hour•6-12 years : 30 mg / 6 hour•>12 years : 60 mg / 6 hour

Treatment …….cont- Topical nasal corticosteroid(beclomethasone, budesonide, fluticasone, mometasone) for children with nasal symptoms are resistant to antihistamine-decongestantInitial dosage : 1-2 spray in each nostril

15

Initial dosage : 1-2 spray in each nostril (2-3 times) per day. After 3-4 days as symptoms improves, the dose / frequency of use are reduced until a minimal effective dosage is reached.Complications : local burning, irritation & epistaxis

Treatment …….cont

- Kortikosteroid oral /IM- Local chromones : kromoglikat,nedokromil � stabilize mast cell- Intra nasal anticholinergik

16

- Intra nasal anticholinergik(ipratropium)- Antileukotrien : montelukast, zafirlukast � blok reseptor

Prognosis

• Depend on age � more severe• The problem in adult � old age

17