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Rhinitis. Allergic or Nonallergic Rhinitis? Taking the Questions Out of Diagnosis and Treatment. Presentation Facts. File size: approximately 1751 KB Number of slides : 143

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rhinitis

Rhinitis

Allergic or Nonallergic Rhinitis?

Taking the Questions Out of Diagnosis and Treatment

presentation facts
Presentation Facts
  • File size: approximately 1751 KB
  • Number of slides: 143
  • This presentation was designed for the user to select sections for their own presentations, or to use in its entirety.
  • Evidence-Based CME: Web site addresses for all EB recommendations are available near the end of this presentation.
  • These slides were prepared by the AAFP and content should not be modified in any way. If content is changed, it is the user’s responsibility to remove both the AAFP and the CME logos. Instructions to remove logos: from menu, select VIEW, MASTER, SLIDE MASTER; select the logos and delete; to return to the original slide view, select VIEW, SLIDE
acknowledgments
Acknowledgments

This is a presentation of the American Academy of Family Physicianssupported by an educational grant from Aventis Pharmaceuticals

The AAFP gratefully acknowledges Harold H. Hedges, III, M.D.

andSusan M. Pollart, M.D.for developing the content for the AAFP

andHarold H. Hedges, III, M.D. and Lincoln Diagnostics for providing the photo images included in this slide presentation.

acknowledgments1
Acknowledgments

Harold H. Hedges, III, M.D.Private Practice

Little Rock Family Practice Clinic

Little Rock, Arkansas

and

Susan P. Pollart, M.D.Associate Professor of Family MedicineUniversity of Virginia Health SystemCharlottesville, Virginia

upon completion of this presentation you should be able to
Upon Completion of This Presentation You Should be Able To:
  • Distinguish allergic, nonallergic and mixed rhinitis from other upper respiratory diseases
  • Identify each entity utilizing history, physical exam, appropriate lab tests, and allergy screening utilizing either skin prick test or in vitro testing
  • Define the pathophysiology of allergic rhinitis
  • Identify environmental allergens common to the geographic area as well as triggers found in the home and work place
  • Identify pharmacologic and nonpharmacologic treatment options for managing allergic and nonallergic rhinitis
  • Recognize when further allergy testing or referral to an allergist might be indicated
evidence based rhinitis care
Evidence-based Rhinitis Care
  • Most guidelines/algorithms presented for treatment of rhinitis are based on expert opinion, not strong evidence
  • Experience from experts’ practices may not apply to a family care setting
  • Emphasize what treatments have evidence-based support and be knowledgeable about optional treatments
evidence based recommendations
Evidence-Based Recommendations
  • Practice Recommendation: Treat patients diagnosed as having allergic seasonal rhinitis with prophylactic medications (antihistamines and/or intranasal corticosteroids).
  • Practice Recommendation: Prescribe intranasal corticosteroids to control allergic rhinitis symptoms.
  • Practice Recommendation: Educate patients with allergic rhinitis about avoidance activities.
  • Practice Recommendation: Reserve immunotherapy for patients with allergic rhinitis for whom optimal avoidance measures and medication therapy are insufficient to control symptoms.

All recommendations available at: http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=158. Accessed August 2003.

epidemiology of rhinitis
Epidemiology Of Rhinitis
  • Affects 100% of the population
  • Often self-limited and associated with viral URI
  • With chronic symptoms, determining etiology guides therapy
  • Major separation is between allergic, nonallergic and mixed rhinitis
epidemiology of rhinitis1
Epidemiology Of Rhinitis
  • Allergic rhinitis was reported the second mostprevalent chronic condition in the United States in 1994
  • Affects 40 to 50 million people
  • Incidence highest in people ages 15-25 years
  • Estimates of nonallergic rhinitis lacking
  • In one study, 57% of patients with chronic rhinitis had nonallergic or mixed rhinitis
allergic rhinitis
Allergic Rhinitis
  • 50% patients symptomatic > 4 months/year
  • 20% patients symptomatic > 9 months/year
  • 10,000 children out of school daily
  • 10,000,000 office visits annually
  • 2,000,000 days of missed school
  • And this accounts only for allergic rhinitis, nonallergic rhinitis is another issue

Blais, MS. Costs of allergic rhinitis in Current Views of Rhinitis

daily costs of rhinitis
Daily Costs of Rhinitis

production

absenteeism

diseases

  • Second generation antihistamines $2 to 2.50/d
  • Steroid nasal sprays $1.40 to 1.90/d
  • Decreased cost of lost production?
  • Cost associated with absenteeism?
  • Cost associated with associated diseases?
impact of allergic rhinitis
Impact of Allergic Rhinitis
  • $5.3 billion for direct and indirect costs in year 1996
  • Affects 10% to 30% of adults, 40% of children
  • Results in more than 2 million lost school days/year
allergic or nonallergic
Allergic or Nonallergic?
  • A dilemma for family care physicians
  • Allergic? Nonallergic? Mixed?
  • Can we distinguish rapidly in the course of a busy day?
  • Is there a quick, cost-effective test?
approach to dx and rx
Approach to Dx and Rx
  • Hypertension, diabetes, infections
    • Hx/Px>>>>Lab>>>>Dx>>>>Rx
  • Rhinitis
    • Hx/Px>>>>Dx>>>>Rx
    • Dx may be wrong up to half of the time
classification of rhinitis
Classification of Rhinitis
  • Allergic Rhinitis
    • Seasonal allergic rhinitis (SAR)
    • Perennial allergic rhinitis (PAR)
  • Nonallergic Rhinitis
    • Infectious
    • Idiopathic or vasomotor
    • Drug-induced
      • Rhinitis medicamentosa
    • Hormonal
    • Anatomical
types of rhinitis
Types of Rhinitis

Pure allergic rhinitis 43%

Pure nonallergic rhinitis 23%

Mixed 34%

100%

57% Non allergic component

National Allergy Advisory Council meeting, The broad spectrum of rhinitis: etiology, diagnosis, and advances in treatment. St. Thomas, US Virgin Islands; 1999.

annals of allergy asthma and immunology vol 2 may 1999
Annals of Allergy, Asthma, and ImmunologyVol 2., May 1999

“Every physician seeing a suspected allergic patient should consider testing for allergen-specific IgE to identify the specific cause.”

Addresses the difficulty of differentiating the types of rhinitis on the basis of history and physical alone

why bother defining rhinitis
Why Bother Defining Rhinitis?
  • Provides evidence leading to medication selection
  • Reduces cost of inappropriate medications
  • Overall, patients have a better understanding of their disease when their physician can explain specifically
defining the types of rhinitis
Defining the Types of Rhinitis
  • Helps in discussing expectations of medication or other treatment
  • Helps explain why some allergic patients do not fully respond to antihistamines (nonallergic component does not respond to antihistamines)
  • Helps explain why some allergic patients on immunotherapy do not totally respond to treatment (the nonallergic component has not been addressed)
quality of life issues
Fatigue

Concentration

Nuisance

Sleep disturbance

Emotional well being

Social interactions

Missing school/work

Halitosis

Decreased daily production

Impaired studying

Sniffing/snorting

Blowing nose

Quality-of-Life Issues
quality of life in seasonal allergic rhinitis overall rqlq
Quality of Life in Seasonal Allergic RhinitisOverall RQLQ

Fexofenadine 120 mg qd is significantly better than loratadine in improving quality of life with respect to SAR symptoms

0.0

-0.4

Change from baseline†

(mean)

-0.8

Lor vs placebo: NS

Fex vs placebo: P <0.005

Fex vs Lor: P 0.03

-1.2

-1.6

Fex 120 mg qd

Placebo

Lor 10 mg qd

† Baseline score ~ 3.0

van Cauwenberge, et al. Clin Exp Allergy: 2000;30:891.

pathophysiology
Pathophysiology
  • Direct effects of histamine
  • Indirect effects of histamine
  • Other mediators of the immune response
effects of histamine in the allergic reaction
Effects of Histamine in the Allergic Reaction

Direct:

  • Histamine receptors: activation
  • Mast cells and basophils: destabilization
  • Endothelial cells: increase expression of adhesion molecules
  • Epithelial cells: increase expression and production of cytokines, chemokines and adhesion molecules
  • Macrophages: increase IL-6 production
  • T-cells: increase cytokine production

Adcock. Clin Exp Allergy Rev. 2002;2:85-88.

Bousquet J. et al. J Allergy Clin Immunol. 2001;108:S147-S333.

Marone et al. Int Arch Allergy Immunol. 2001;124:249-52.

effects of histamine in the allergic reaction1
Effects of Histamine in the Allergic Reaction

Indirect:

  • Eosinophils: increase maturation and migration, and promotion of apoptosis
    • IL-5, GM-CSF, RANTES, eotaxin, adhesion molecules
  • Neutrophil: increase migration and adhesion
    • IL-8, leukotrienes, adhesion molecules
  • IgE: increase production
    • IL-4, IL-13

Adcock. Clin Exp Allergy Rev. 2002;2:85-88

Bousquet J. et al. J Allergy Clin Immunol. 2001;108:S147-S333

Marshall GD. JACI. 2000;106:S303-309

other mediators of the allergic reaction
Other Mediators of the Allergic Reaction
  • Mast cells also influence AR through release of other proteins, metabolites, and cytokines
    • Degranulation releases proteins (e.g., tryptase and chymase) and proteoglycans (including heparin and chondroitin sulfate)
    • Arachidonic acid metabolites (including leukotrienes and prostaglandins) synthesized de novo following cell activation
    • Variety of preformed cytokines released
  • Occurs more rapidly than from activated T-cells
    • Antihistamines inhibit antigen-induced release of histamine and other mediators from mast cells and basophils in vitro

Bousquet J. et al. J Allergy Clin Immunol. 2001;108:S147-S333

De Paulis A. et al. (Abstract). Allergy. 1999;54 (suppl 52):278

Lindstedt KA. et al. J Lipid Res. 1992;33:65-75

Marshall GD. JACI. 2000;106:S303-309

early response
Early Response
  • Leakage of blood vessels
  • Mucosal edema
  • Rhinorrhea
  • Secretion of mucoglycoconjugates
    • Congestion
    • Nasal itching
    • Sneezing
managing patients with allergic rhinitis
Managing Patients with Allergic Rhinitis

Four general principles of allergy management

1. Education and monitoring

2. Avoidance of trigger factors

3. Pharmacotherapy

4. Immunotherapy

The Allergy Report. Am Acad Allergy Asthma Immunol. 2000.

Dykewicz M, et al. Ann Allergy Asthma Immunol. 1998;81:478-518.

case study
Case Study

Patient presents with runny nose, nasal congestion, constantly clearing his throat, sniffing, snorting, disruptive to fellow students. Requests a prescription for an antihistamine “like the one I saw on TV.”

  • What else do you need to know before prescribing medication?
  • What physical signs can help you?
  • What quick, in-office tests can help you with a diagnosis?
what do you need to know in addition to symptoms
What Do You Need to Know in Addition to Symptoms?
  • Age at onset
  • Are sx acute, chronic, recurrent, seasonal or perennial?
  • What causes the symptoms?
  • What is the response to antihistamines?
  • Does patient have any pets (cats, dogs, animals with hair)?
  • Any associated illnesses (asthma, skin rash, otitis media)?
  • Is there a family history of allergy?
allergic patients generally have
Allergic Patients Generally Have
  • Early onset of symptoms (70% < age 20)
  • Family history of allergy
  • Seasonal symptoms
  • Symptoms with animal exposure
  • Symptoms worse outdoors
  • Symptoms worse near fresh-cut grass
  • Symptoms better in air conditioning
  • Tobacco and chemicals are not primary excitants
  • Previous immunotherapy was helpful
bimodal occurrence of allergic rhinitis
Bimodal Occurrence of Allergic Rhinitis
  • First appears in elementary school ages
  • Abates during middle and high school ages
  • Reappears in 20s and 30s
nonallergic patients generally have
Nonallergic Patients Generally Have
  • Later onset of symptoms (70% > age of 20)
  • No family history of allergy
  • Tobacco smoke and chemicals primary excitants
  • Weather changes provoke symptoms
  • No seasonal aspect to symptoms
  • No symptoms with exposure to dust
  • No symptoms with exposure to animals
risk factors for rhinitis
Risk Factors for Rhinitis
  • Asthma, atopic dermatitis, allergy
  • Family history of allergy
  • Daycare centers
  • Viral infections
  • Occupational exposures
  • Hobbies, weekend activities
  • Flying
causes of rhinitis
Allergy

NARES syndrome

Occupational

Hormonal

Drug induced

Anatomic defects

Irritants

Adverse food reaction

Emotional

Atrophic

Ciliary dyskinesia

Immunodeficiency diseases

Causes of Rhinitis
rhinitis case study
Rhinitis — Case Study
  • 8-year-old female with year-round sneezing, nasal congestion, worse in spring and fall, recurrent otitis media, occasional wheezing with URIs, misses 20 plus days of school per year, sniffling, throat clearing. Lethargic, tired all the time. Father is allergic. Not doing well in school. This is her 4th office visit this year.
  • Afebrile. Allergic shiners. Nasal discharge. Nasal crease. Bluish tint to congested nasal mucosa. Lungs are clear.
diagnosis typical patient with allergic rhinitis with its common morbidities
Diagnosis: Typical Patient with Allergic Rhinitis with its Common Morbidities
  • Perennial allergic rhinitis with seasonal exacerbations
  • Recurrent otitis media
  • Asthma triggered by viral infections
symptoms of allergic rhinitis
Symptoms of Allergic Rhinitis
  • Sneezing
  • Nasal congestion
  • Watery nasal discharge
  • Itchy watery eyes
  • Postnasal drip
  • Itching
physical changes of allergic rhinitis
Physical Changes of Allergic Rhinitis
  • Pale blue, edematous turbinates
  • Clear, watery nasal discharge
  • Crease from nasal salute
  • Lymphoid hyperplasia
  • Watery, itchy eyes
allergic rhinitis and concomitant disease
Allergic Rhinitis and Concomitant Disease
  • Management of allergic rhinitis may decrease exacerbations of sinusitis, asthma and otitis media
  • Early immunotherapy for allergic rhinitis has been shown to decrease the development of asthma
evaluation of rhinitis
Evaluation of Rhinitis
  • History and physical
  • Sinus transillumination
  • Direct visualization with nasal specula
  • Rhinoscopy
  • Nasal smear
  • Allergy screening tests (skin tests or RAST)
  • Imaging for persistent disease
physical exam nares
Physical Exam-NARES
  • External appearance, evidence of trauma
  • Color, consistency of nasal discharge
  • Mucosal swelling
  • Presence of odor
  • Polyps, septal deviation, concha bullosa
  • Tenderness over sinuses
physical examination
Physical Examination
  • Eyes: conjunctivitis, dark circles, Dennie’s lines
  • Ears: OM, TM mobility, serous otitis
  • Mouth: mouth breathing
  • Lungs: wheezing
nasal smear
Nasal Smear
  • Clear nose of secretions
  • Gently scrape sample from mucosa of inferior or middle turbinate with plastic ear spatula or cotton swab
  • Wright’s or Hansel’s stain
  • Eosinophilia
    • Allergy (present in 90% of allergic patients)
    • NARES syndrome
    • Aspirin sensitivity
  • Neutrophilia
    • Infection
sinus x rays and ct scans only for chronic or recurrent disease
Sinus X-rays and CT Scans Only for Chronic or Recurrent Disease
  • Sinus x-rays (cost $353: local hospital)
    • Not needed for diagnosis of acute rhinosinusitis
    • Water’s view for the maxillary sinuses
    • Town’s view for ethmoid and frontal sinuses
    • Lateral view for the sphenoid
  • Limited coronal CT scan (cost $397: local hospital)
    • Osteomeatal complex
    • All sinuses visualized
  • CT scan gives much better imaging for minimal increased cost
rhinoscopy
Rhinoscopy
  • Nasal polyps
  • Septal deviation
  • Concha bullosa
  • Eustachian tube dysfunction
  • Causes of hoarseness
  • Adenoid tissue
  • Tumors
treatment of allergic rhinitis
Treatment of Allergic Rhinitis
  • Avoidance of identified allergens
  • Nasal steroids
  • Antihistamine nasal spray
  • Antihistamines (sedating and nonsedating)
  • Decongestants
    • Nasal sprays (limited 2-3 days)
    • Oral preferred (limited by side effects)
  • Nasal irrigation
  • Leukotrienes
general treatment modalities
General Treatment Modalities
  • Vigorous exercise
  • Posture
  • Avoidance procedures
  • Saline irrigation
nasal irrigation
Nasal Irrigation
  • Commercial buffered sprays
  • Bulb syringe
    • 1/4 tsp of salt to 7 ounces water
  • Waterpik with lavage tip
    • 1 tsp salt to reservoir
  • Disposable enema bucket
    • 2 tsp salt, 1 tsp soda per quart of water
nasal irrigation1
Nasal Irrigation
  • Washes away irritants
  • Moistens the dry nose
  • Waterpik with nasal irrigator
  • Ceramic irrigators
  • Enema bucket with normal saline and soda
    • “hose-in-the-nose”-- $2.50
treatment of mild allergic rhinitis occasional exposure symptoms step 1
Treatment of MildAllergic Rhinitis Occasional exposure/symptoms Step 1
  • Environmental control
  • Saline irrigation
  • Monotherapy
    • Nasal steroid or
    • Nonsedating antihistamine or
    • Astelazine nasal spray
treatment of moderate allergic rhinitis sx may last for months to one year step 2
Treatment of Moderate Allergic Rhinitis Sx May Last for Months to One Year Step 2
  • Environmental control
  • Normal saline irrigation
  • Combination therapy
    • Nasal steroid and
    • Nonsedating antihistamine with or without decongestant or
    • Astelazine
  • Immunotherapy
slide57
Treatment of Severe Allergic Rhinitis Chronic, persistent associated with Sinusitis, Otitis media and asthmastep 3
  • Environmental control
  • Normal saline irrigation
  • NSA+/- decongestant
  • High-dose nasal steroid
  • Afrin 3 days or fewer
  • Oral steroid
  • Immunotherapy
environmental control avoidance
Environmental Control/Avoidance
  • Dust mites
    • Controls: plastic covers, frequent vacuuming of carpet
    • Avoid: overstuffed chairs, curtains, stuffed animals, dust-collecting boxes under bed
  • Cockroaches
    • Poisoning
environmental control
Environmental Control
  • Air conditioning
  • Frequent dusting, cleaning surfaces
  • Air filters
    • Hepa filtration
  • Vacuum cleaners
    • Dry versus water filtration
  • Ionizers
  • Wood burning stoves
environmental control a nimals
Environmental Control — Animals
  • Cats and dogs
    • Unrealistic:
      • Get rid of or give away
    • Realistic:
      • At least out of the house
      • Dogs usually will become “yard dogs”
      • Cats will stay in the house
      • Out of the bedroom
      • Washing cats 1-2 times weekly
environmental control of molds
Environmental Control of Molds
  • Remove sources of mold growth
    • Piles of leaves, clothes, foods
  • Control humidity
    • Basements, closets, bathroom areas
  • Increase ventilation
  • Remove under-house water
  • Fungicides
  • Clean humidifiers, vaporizers
pharmacotherapy
Allergic rhinitis

Antihistamines

OTC

Nonsedating

Nasal steroids

Nasal cromolyn

Astelazine nasal spray

Decongestants

Nonallergic rhinitis

Antihistamines

Drying effect

Decongestants

Astelazine

Ipatropium

Nasal steroids

NARES syndrome

Pharmacotherapy
nasal steroids
Nasal Steroids
  • Flonase
  • Beconase
  • Nasonex
  • Nasacort
  • Rhinocort
  • Vancenase
  • Tri-Nasal
nonsteroid nasal sprays
Nonsteroid Nasal Sprays
  • Astelazine
  • Atrovent
  • Nasalcrom
  • Saline
comparison of various approaches to the treatment of allergic rhinitis
Comparison of Various Approaches to the Treatment of Allergic Rhinitis

Sneezing Discharge Itch Congestion Side effects

Antihistaminestraditional (A) +++ +++ +++ + +++

Nonsedating(NSA) +++ ++ +++ + – to +

Azelastine +++ ++ +++ + – to +

Decongestants – + – +++ ++

NSA + decongestants +++ +++ +++ +++ ++

Leukotriene antag.* + to ++ + to ++ + to ++ ++ – to +

Cromolyn ++ + + + –

Nasal CCS (NCS) +++ +++ +++ +++ +

NSA + NCS ++++ ++++ ++++ ++++ +

Immunotherapy +++ +++ +++ +++ + to ++

* = Presumed; no data on individual symptoms Nayak AS, et al. Ann Allergy Asthma Immunol. 2002;88:592-600. ++++ = Strongly positive effect; + = Minimal effect

nonallergic rhinitis

Nonallergic Rhinitis

As important as allergic rhinitis

Present in 57% of patients with rhinitis

nonallergic vasomotor rhinitis
Nonallergic/Vasomotor Rhinitis
  • Perennial or episodic symptoms
  • Chronic, nonpruritic rhinorrhea/congestion
  • Negative nasal eosinophils
  • Negative allergy screening
  • Nonallergic excitants
    • Viruses
    • Chemicals, tobacco smoke, potpourri
    • Nonallergic foods
    • Weather changes
symptoms of nonallergic rhinitis
Symptoms of Nonallergic Rhinitis
  • Nasal congestion is prominent
  • Sneezing and nasal itching uncommon
  • Concomitant asthma is less likely
  • Eye symptoms are fewer
  • Postnasal drip
  • Fatigue
  • Loss of sense of smell and taste
tests helpful in diagnosing nonallergic rhinitis
Tests Helpful in Diagnosing Nonallergic Rhinitis
  • Nasal smear will be void of eosinophils
    • Eosinophils present in 90% of allergic rhinitis
    • Neutrophils suggest bacterial infection
  • Skin prick tests or in-vitro testing negative
    • Negative allergy testing is the best predictor of the nonallergic state
treatment of nonallergic rhinitis
Treatment of Nonallergic Rhinitis
  • Astelazine nasal spray
  • Steroid nasal spray
  • Nasal irrigation
  • Avoidance
  • Effectiveness of antihistamines questionable
rhinitis case study1
Rhinitis — Case Study
  • 23-year-old has had nasal congestion for the past 23 months. Started as a cold, but symptoms never cleared. “Allergies” several times a year as a child but outgrew them. Never tested. No family hx of allergy. Can’t sleep without his medication.
    • Is he allergic?
    • What is your next question?
rhinitis case study2
Rhinitis — Case Study
  • What medication are you using?
  • Answer: “Afrin, I can’t breath or sleep without it.”
rhinitis medicamentosa
Rhinitis Medicamentosa
  • Rebound congestion from overuse of topical decongestants; oxymetazolone, phenylephrine, cocaine
  • Erythematous mucosa, congestion, punctate bleeding
  • Interstitial edema and vasoconstriction
  • Withdrawal of medication, topical steroids, oral steroids
treatment of rhinitis medicamentosa
Treatment of Rhinitis Medicamentosa
  • Initiate topical steroid bilaterally, discontinue decongestant in one nostril, then the second nostril one week later
  • One-week dose of tapering steroids
  • Evaluate for the underlying cause of the rhinitis
medications that may cause rhinitis
Aldomet

Cardura

Catapres

Corgard

Hytrin

Ismelin

Minipres

Moduretic

Normodyne

Trandate

Viagra

Wytensin

Medications That May Cause Rhinitis
hormonal causes of rhinitis
Hormonal Causes of Rhinitis
  • Pregnancy
    • Second month to term
  • Puberty
  • Oral contraceptives
  • Hypothyroid state
rhinitis of pregnancy
Rhinitis of Pregnancy
  • Mild symptoms may have been present before (pregnancy aggravated symptoms)
  • Increase in circulating blood volume
  • Progesterone induced smooth muscle relaxation
  • Hormonal effect on nasal mucosa
treatment of rhinitis in pregnancy
Treatment of Rhinitis in Pregnancy
  • Caution with medication usage
  • Nasal saline sprays, steam inhalation
  • Avoidance of known triggers
  • Topical medical therapy rather than systemic when possible
  • Oral pseudoephedrine
  • Chlorpheniramine
rhinitis case study3
Rhinitis — Case Study
  • 28-year-old with a two-year history of profuse rhinorrhea. No history of rhinitis or asthma as child. Occasional sneezing, little congestion.
  • Clear nasal discharge on exam, pharynx, tympanic membrane, lungs all normal.
  • Skin test is negative with good positive control.
    • What in-office test will make the diagnosis clear?
nares syndrome
NARES Syndrome
  • Nasal smear revealed marked eosinophilia
  • Diagnosis: NARES syndrome nonallergic rhinitis with eosinophilia
nares syndrome1
NARES Syndrome
  • Perennial symptoms
    • Sneezing
    • Rhinorrhea
    • Pruritis
  • Occasional loss of smell
  • Nasal smear positive for eosinophils
  • Allergy screen is negative
nasal mastocytosis is rare
Nasal Mastocytosis is Rare
  • Basophilic metachromic nasal disease
  • Histologic diagnosis
  • Mast cell infiltration of the mucosa
  • No eosinophils
rhinitis case study4
Rhinitis — Case Study
  • 2 year-old male presents with purulent, foul smelling rhinorrhea, pain on pressure about the left side of nose. No sneezing, is congested.
  • Temp 99.2°, irritable, crying, hard to examine. Left TM red. Lungs clear. Nose is congested, purulent rhinorrhea, more on left than right. Fights you trying to examine his nose and throat.
  • Diagnosis?
acute bacterial rhinitis secondary to foreign body
Acute Bacterial Rhinitis Secondary to Foreign Body
  • Unilateral purulent rhinorrhea
  • Localized pain
  • Leucocytes on nasal smear
  • Erythema and swelling of the area involved
  • Distortion of the nose from swelling
  • Odor
atrophic rhinitis ozena
Atrophic Rhinitis (Ozena)
  • Found in patients who have had radical nasal tissue removal for congestion
    • Removal of inferior and or middle turbinates
      • “Empty nose syndrome”
  • Excessive drying, crusting and infection
  • Atrophic changes in the elderly
  • Klebsiella colonization
treatment of atrophic rhinitis
Treatment of Atrophic Rhinitis

Nasal irrigation 3-4 times per day for 2-3 months, then 1-2 times per day indefinitely

rhinitis case study5
Rhinitis — Case Study
  • 45-year-old female with no history of previous symptoms of rhinosinusitis presents with headaches, daily nasal congestion and fatigue for 3-4 months. No hx of viral URI. No family hx of allergy. No changes in cosmetics, no additions to house, no new clothes. No pets. No food reactions known.
    • What other element of a thorough history might give you a clue as to diagnosis?
rhinitis case study6
Rhinitis — Case Study
  • Where do you work?
  • How long have you worked there?
  • Do your symptoms coincide with changing jobs?
  • Are you more symptomatic at work than at home?
  • Do your symptoms clear on the weekend or on vacation?
occupational rhinitis
Occupational Rhinitis
  • Patients experience symptoms in workplace
  • Symptoms improve on weekends/vacation
  • May be allergic or nonallergic
  • May coexist with occupational asthma
  • Treatment is avoidance
    • Move to another area in the workplace
    • Move to another job
causes of occupational rhinitis
Causes of Occupational Rhinitis
  • Sick building syndrome
    • Department of Ecology and Environmental Protection
  • Gasses from office machines
    • Inks, paper
  • Perfumes
  • Paints, carpet, carpet glue
  • Laboratory animals
common workplaces for occupational rhinitis
Beauty salons

Clothing stores

Supermarkets

Auto body spraying

Service stations

Woodworking

Pesticide industry

Plastic manufacturing

Tanneries

Paper industry

Gardening products

Insecticides

Food industry

Laboratory animals

Office machinery

Paints, chemicals

Common Workplaces for Occupational Rhinitis
common chemical exposures causing rhinitis
Gasoline/diesel fuels

Chlorine

Perfumes

Cleaning agents

Room deodorizers

Hair dyes

Permanent solutions

Paints

Auto body paints

Herbicides

Potpourri

Burning candles

Petroleum products

Formaldehyde

New clothing odor

Hair spray

Toluene

Ammonia

Acids

Common Chemical Exposures Causing Rhinitis
mechanical causes of rhinitis
Deviated nasal septum

Nasal polyps

Foreign body

Tumors of the nose

Congenital atresia

Meningocoele

Adenoid hypertrophy

Variants of the osteomeatal complex

Concha bullosa

Mechanical Causes of Rhinitis
gustatory rhinitis
Gustatory Rhinitis
  • Rhinorrhea and/or nasal congestion related to eating
  • Treatment is identification and elimination
  • Common causes of gustatory rhinitis
    • Wines
    • Cheeses
    • Spicy foods
food reactions
Food Reactions
  • Diagnosed by skin prick tests, RAST or elimination diet
    • Skin prick tests, in-vitro testing will only diagnose IgE-related foods
    • Elimination diet will diagnose all types adverse food reactions
vasculitides autoimmune and granulomatous causes
Vasculitides, Autoimmune and Granulomatous Causes
  • Churg-Strauss Syndrome vasculitis
  • Systemic lupus erythematosis
  • Relapsing polychondritis
  • Sjogren’s syndrome
  • Sarcoidosis
  • Wegener’s granulomatosis
pharmacotherapy1
Allergic rhinitis

Antihistamines

OTC

Nonsedating

Nasal steroids

Nasal cromolyn

Astelazine nasal spray

Decongestants

Nonallergic rhinitis

Antihistamines

Drying effect

Decongestants

Astelazine

Ipatropium

Nasal steroids

NARES syndrome

Pharmacotherapy
treatment of bacterial rhinitis
Treatment of Bacterial Rhinitis
  • Antibiotics
    • Ointment
    • Systemic
  • Saline sprays
treatment of atrophic rhinitis1
Treatment of Atrophic Rhinitis
  • Saline irrigation
  • Ipatropium
nasal polyps
Nasal Polyps
  • Grape-like clusters
    • Maxillary sinus
  • Inflammatory process
  • One third associated with asthma
    • Asthma-aspirin-polyp triad
  • High rate of recurrence
nasal polyps1
Nasal Polyps
  • Allergy control
  • Intranasal steroids
  • Systemic steroids
  • Avoidance of ASA, NSAIDs
  • Polypectomy
  • Ethmoidectomy
importance of allergy testing in the family practice setting
Importance of Allergy Testing in the Family Practice Setting
  • Distinguishes between allergic, nonallergic and mixed rhinitis
  • Aids in selecting specific pharmacotherapy
  • Identifies specific allergens to be avoided and/or treated by immunotherapy when indicated
indications for allergy testing
Indications for Allergy Testing
  • Identification of allergens
  • Chronic or recurrent symptoms
  • Symptoms not controlled by avoidance and medication
  • Medication not tolerated
  • Decrease cost of medication
contraindications for allergy skin testing
Contraindications for Allergy Skin Testing
  • Uncontrolled asthma or recent asthma attack
    • PEFR must be above 70% personal best effort
  • Cardiac problems
  • History of hymenoptera sensitivity
  • History of anaphylaxis of any kind
    • Shellfish
    • Medications
refer to an allergist
Refer to an Allergist
  • Hymenoptera sensitivities
  • Antibiotic desensitization
  • Anesthetic testing
  • Patients with history of anaphylaxis
    • Medication
    • Shellfish
    • Peanut or other food reactions
allergy testing and allergy screening in family practice

Allergy Testing and Allergy Screening in Family Practice

A very cost effective procedure to learn

allergy testing in family practice
Allergy Testing in Family Practice
  • Easy to learn to perform
  • Results interpreted against negative and positive controls
  • Safe with good patient selection
  • Test results immediate
  • Patient can see, feel and scratch response
    • Aids in avoidance procedures
instruments used in allergy testing
Instruments Used in Allergy Testing
  • Invivo tests
    • Individual skin prick tests
      • DuoTip
      • Morrow Brown needle
      • GreerPick
    • Multiple antigen applicators
      • MultiTest
      • Quintest
  • Invitro tests
    • Modified in-vitro testing
    • CAP system
skin testing disadvantages
Skin Testing Disadvantages
  • Affected by medications
    • Antihistamines
    • Steroids
  • Patient discomfort
  • Rare possibility of anaphylaxis
  • Dermagraphism
  • Chronic skin disorders
  • Very young and atrophic skin
puncture prick testing
Puncture/Prick Testing

Figure 1

  • Disease-free site
  • Swipe with alcohol
  • Apply drop of antigen (1:10 or 1:20 conc.)
  • Prick skin at 45 to 60 degree angle, or puncture at 90 degrees
  • Gently lift device, no bleeding should occur
  • Read positive control in 10 minutes
  • Read allergens in 15-20 minutes

Example of a skin prick/puncture epicutaneous test

multiple antigen testing
Multiple Antigen Testing
  • Alcohol wipe and dry area to be used
  • Remove device from package
  • Place in loading dock
  • Apply to forearm
  • Read positive control in 10 minutes
  • Record allergen response in 15-20 minutes
multiple antigen testing cont d
Multiple Antigen Testing cont’d

Figure 3

Figure 2

Example of multiple-puncture device in its loading dock

Example of multiple-puncture device allowing simultaneous placement of six allergens plus a positive and negative control

multiple antigen testing cont d1
Multiple Antigen Testing cont’d

Figure 5

Figure 4

Example of positive and negative skin responses to allergens applied with a multiple-puncture device; note the positive and negative control sites

Example of application of a multiple-puncture device to the forearm

skin testing precautions
Skin Testing Precautions
  • Physician always present
  • Emergency equipment available and current
    • Adrenalin and albuterol in testing room
  • Determine patients’ most recent use of antihistamines, steroids, H2 blockers
  • Is patient on a beta blocker?
    • Switch medications or in vitro testing
grading of multitest
Grading of MultiTest

0 No reaction-1-3 mm wheal

1+ Erythema with 3mm wheal

2+ Erythema with 5 mm wheal

3+ Erythema with 7-10 mm wheal

4+ Erythema with >10 mm wheal

5+ Erythema with >10 mm wheal and pseudopods

reading and recording results
Reading and Recording Results
  • Best done by physician scoring and nurse recording
  • If reaction is borderline, read as the higher class
    • Example
      • Difficulty determining if result is #3 or #4 record as #4
positive and negative controls
Positive and Negative Controls
  • Imperative to use to validate skin response
  • Positive negative control = dermagraphism
  • Negative positive control = medication reaction or hypoactive skin
in vitro testing
In-Vitro Testing
  • Reference laboratory
    • Many available
  • In-office labs
    • Weigh expense involved
indications for in vitro testing
Indications for In-Vitro Testing
  • Dermatographism
  • Eczema
  • Very young skin
  • Atrophic skin
  • Long-acting antihistamines
  • Beta blockers, ACE inhibitors, MAOs
  • Patients with poorly controlled asthma (70%)
  • History of anaphylaxis
rast procedure
RAST Procedure
  • Allergen coupled to paper disc
  • Add patient’s serum
  • Antigen-antibody complex formed
  • Radioactive anti IgE added
  • Anti IgE-antibody-allergen complex formed
  • Gamma counter scoring
rast scoring
RAST Scoring

Class 0 200-500 No allergy

Class 0/1 500-750 Questionable allergy

Class 1 750-1,600 Mild allergy

Class 2 1,600-3,600 Moderate allergy

Class 3 3,600-8,000 More allergic

Class 4 8,000-18,000 More allergic

Class 5 Over 18,000 Most allergic

advantages of in vitro
Advantages of In-Vitro
  • Patient safety, no anaphylaxis
  • Cost-effective screening
  • Not affected by medication
  • No irritating skin reactions
  • Sets safe starting doses for immunotherapy
disadvantages of in vitro
Disadvantages of In-Vitro
  • Patient does not experience the reaction
  • Less sensitive than skin tests (?)
  • Cost per test may be higher
  • RAST requires 3-14 days to get results
rast scoring as a guide to immunotherapy
RAST Scoring as a Guide to Immunotherapy
  • The higher the RAST class the more dilute the starting dose of immunotherapy
  • The lower the RAST class the higher the starting dose of immunotherapy
prescribing immunotherapy based on rast results
Prescribing Immunotherapy Based on RAST Results
  • Blood sample is drawn anytime
  • Serum is removed
  • Sent to lab and processed
  • Results correlated with history
  • Prescription for immunotherapy written
  • Lab makes up immunotherapy sets
allergy screening

Allergy Screening

A most cost effective test to do!

allergy screening1
Allergy Screening
  • Use of 6-10 antigens to determine the presence or absence of allergy
  • Prevalence of sensitization
    • Same allergens common to patients in a geographic area
      • Incidence varies from 20% to 80% per antigen
references
References
  • Nalebuff, DJ. Use of RAST screening in clinical allergy: a cost-effective approach to patient care. Ear Nose Throat J. 1985; 64:107-21.
  • Blok et al. Reported use of 5 antigen screens. Allergy. 1991
screening allergens most common from geographic area
Negative control

Weed (ragweed)

Grass (June)

Tree (oak or elm)

Positive control

House dust mites

Mold (alternaria)

Cat

Screening Allergens-Most Common from Geographic Area
typical midwest screen
Typical Midwest Screen
  • Ragweed
  • House dust mite
  • Cat
  • June grass
  • Oak tree
  • Alternaria
interpretation of screen
Interpretation of Screen
  • All tests negative (except positive control) no allergy is present
  • Positive control and all other test sites negative, hypoactive skin, proceed with in-vitro test
  • Any grass, tree, weed or mold positivecomplete allergy panel
  • House dust mite only positiveavoidance
  • Cat only positiveavoidance
advantages of screen
Advantages of Screen
  • Identifies the allergic and nonallergic
  • Eliminates need for unnecessary testing of nonallergic patients
  • Helps direct pharmacotherapy
  • Demonstrates antigens needing avoidance
  • Cost-effective, reliable
screening with rast
Screening with RAST
  • 6-10 antigens all placed on disc or in a cellulose suspension and tested
  • When positive, additional antigens are tested, usually 25-35 for geographic area
geographic allergy panels
Geographic Allergy Panels
  • 25-40 antigens
  • Unusual animal danders per history
  • Kniker T. MultiTest skin testing in allergy: a review of published findings. Ann Allergy. 1993;71:485-91
  • Foods if indicated
cross reacting pollens
Cross-Reacting Pollens
  • June: rye, sweet vernal, timothy, brome, red top
  • Oak tree species
  • Hickory and pecan trees
  • Ragweed species
before considering immunotherapy
Before Considering Immunotherapy

Always correlate history with test results.

indications for immunotherapy
Indications for Immunotherapy
  • Inadequate control with avoidance and pharmacotherapy
  • Pharmacotherapy for more than 3-4 months per year
  • Intolerable side effects of medication
  • Progressive severity of disease
  • Desire for long-lasting control without Rx
the allergy screen is negative what next
The Allergy Screen is Negative, What Next?
  • Identify nonallergic triggers
  • Elimination diet to look for adverse food reaction
  • Use medications indicated for nonallergic rhinitis
    • Astelazine
    • Intranasal steroids
    • Decongestants
    • Antihistamines are of little value
bibliography
Bibliography
  • The Allergy Report. American Academy of Allergy, Asthma and Immunology, Milwaukee, WI: 2000. Available at www.aaaai.org.
  • Middleton E, et al. Allergy: principles and practices 5th ed. St. Louis, Mosby: 1998.
bibliography1
Bibliography
  • Altman LC, Becker JW, Williams PV. Allergy in Primary Care. Philadelphia: Saunders; 2000.
  • Squillace S, Hedges H. Asthma, allergic rhinitis and immunotherapy. American Academy of Family Physicians; 1998.
  • Kaliner MA, ed. Current reviews of rhinitis. Curr Med; 2002.
allergy resources available to family physicians
Allergy Resources Available to Family Physicians

American Academy of Family Physicians 1-800-274-2237

Antigen Laboratories1-816-781-5222

Allergy Laboratories 1-800-654-3971

National Procedures Institute 1-800-462-2492

Pan American Allergy Society1-210-997-9853

evidence based recommendations1
Evidence-Based Recommendations
  • Practice Recommendation: Treat patients diagnosed as having allergic seasonal rhinitis with prophylactic medications (antihistamines and/or intranasal corticosteroids).
  • Practice Recommendation: Prescribe intranasal corticosteroids to control allergic rhinitis symptoms.
  • Practice Recommendation: Educate patients with allergic rhinitis about avoidance activities.
  • Practice Recommendation: Reserve immunotherapy for patients with allergic rhinitis for whom optimal avoidance measures and medication therapy are insufficient to control symptoms.

All recommendations available at: http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=158. Accessed August 2003.

thank you
Thank You

This has been a presentation of the American Academy of Family Physicians