Allergic rhinitis
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ALLERGIC RHINITIS
Syam chandran C
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Definition
• A Symptomatic disorder of nose induced by an IgE mediated inflammation after allergen exposure.
• Associated with episodic attacks of sneezing, watery Rhinorhoea and watering of the eyes.
• May also present with tightness of chest due to sub clinical bronchospasm.
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Etiology
• Allergic rhinitis is the commonest chronic disease. Its causation is multi factorial. Manifestation is multifocal.
• The symptoms of patients and type of allergy depends on a number of factors.
• Allergens are the causal substance of AR. They are capable for producing the body produce IgE antibodies.
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• Factors may be classified as :
–Precipitating factors–Predisposing factors
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Precipitating factors
• Aerobiological flora : This is determined by the allergens present in that environment of which inhalant allergen is more common.
• Nasal physiology : Altered nasal cycle
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Predisposing factors
• Hereditary : Multiple gene interactions are responsible for allergic phenotype. Genes of chromosomes 5,6,11,12,14 seem to control inflammatory process in atopy. A family history of similar or allied complaints is common.
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• Endocrine : Pubertal , marital, natal and menopausal conditions have the potential to influence the nose significantly.
• Psychological
• Focal Sensitivity
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• Physical : Changes in humidity, temp and pollution of air can contribute to the development of allergic rhinitis. Living conditions like residential and workplace conditions also play an act.
• Infections
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• Age and Sex
• Industrialization and urbanization
• IgA Deficiency
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Common allergens
• Pollens : amaranthus, cassia, prosopis, ricinus, albizia, panthenium, artemisia
• Molds : the commonest fungal spores in India are cladosporium, pencillium, trichoderma etc
• Insects : bed bugs, cockroach, house flies, mosquito, fleas etc• Animals : pets like cat and dog. Also from horse, rabbits,
guinea pigs, monkeys, mice.• Dust mites : dermatophagoides can sensitize people.• Ingestants : eggs, strawberries, nuts, fish. Citrus fruits and
nuts also seems common allergens.
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Classifacation
• Seasonal
• Perennial
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Seasonal
• Hay fever or summer cold.
• Stiffy/runny nose.• Paroxysm of sneezing• Itchy nose/eyes/throat.• Excess mucus in nose/
throat
Hay fever – It is a misnomer because neither it is caused by hay nor it produces fever
Summer Cold – Should not be confused with acute rhinitis that is caused by virus and not by allergens
Rose fever – It is also a misnomer because colorful or fragrant flowering plants rarely cause allergy as there pollens are too heavy to be airborne
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Perennial A R
• Caused by allergens that are present throughout the year include animal dander, cosmetics molds, food and other pets.
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Clinical features
• Diagnostic symptoms including the following :• Nasal pruritus • Paroxysms of sneezing• Rhinorrhea
• Pale bluish edematous nasal mucosa.
• Bulky edematous turbinates with bluish / purple tinge of the mucosa
• Mucosa coated with clear/ mucoid secretions• In advance stage – polyp may be formed• Thickening of the nasal septum
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Classical signs :• Overriding maxillary incisors• High arched palate• Allergic shiners• Allergic salute• transverse crease above the tip of nose and lower eye
lid • Conjunctival congestion• Peri-orbital swelling
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Investigations
• Total WBC and DC• AEC• Histamine test• Nasal Smear• Intranasal provocation test
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Specific tests (in vivo tests)
Skin test :
Sub Cuticular test or (prick/scratch test)• More accurate and lower incidence of
false positive results.• Contra indicated in case of
dermographism, anti histaminic, anti- inflammatory or decongestant treatment.
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Intra dermal skin test :• Higher chance of anaphylaxis and has to
be done only with resuscitation equipment ready
Skin end point titration test• Quantitative intradermal test for specific
allergen
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Other tests
Nasal challenge (nasal provocation test)
Nasal cytology• Using dry wipe technique without surface
anesthesia• Following cell types are noted :• Eosinophil• Mast cells• Epithelial cells • Lymphocytes• Neutrophils• Goblet cells
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In vitro tests
• RAST (Radio-allergo-sorbant-test)
• FAST (Fluro-allergo-sorbant-test)
• PRIST (Paper immuno-allergo-sorbant test)
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Other tests
• X ray PNS
• CT OMC
• Nasal endoscopy
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Treatment
Medical
• Avoidance of Allergen
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• Pharmaco therapy
a) Anti histaminic drugs like loratidine, rupatidine, levocetrizine etc…
b) Steroids like fluticasone, momentasone, beclomethasone, budesonide etc…
c) Sodium chromoglycate stabilizes the mast cells and prevents its degranulation
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d) Decongestants pseudoephedrine hydrochloride, phenylephidrine hydrochloride etc…
e) Saline irrigation of the nasal cavities
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• Immuno therapy
• In case where the above methods got failed and in severe AR.
• Helps in reducing the specific serum IgE level and a decrese in basophil sensitivity and increase IgG blocking antibody level which help in preventing the allergen from reaching the mast cells and thus preventing there degranulation.
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• Surgical– Limited to reduction of the size of the
turbinates , correction of septal deviation and limited endoscopic sinus surgery if sinus are involved.
– Cauterisation– Septoplasty– Inferior turbinectomy– Laser and cryosurgery
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THANK YOU ALL