AR VS CRS

1. AR VS CRS DR NOR AMILAH BINTI MOHD RAMLI ORL HEBHK 13 JULY 2023

2. Introduction • Allergic rhinitis (AR) represents a global health concern where it affects approximately 400 million people worldwide. • The prevalence of AR has increased over the years along with increased urbanization and environmental pollutants thought to be some of the leading causes of the disease. • It is reported to affect approximately 25 and 40% of children and adult globally, respectively.

3. rHINITIS • -  Tissue inflammation & nasal hyperfunction which lead to symptom of rhinorrhea, nasal obstruction and sneezing/ itchiness (2 out of 3), occurring > 1hr/day • -  Allergic vs non-allergic • Allergic • Intermittent (seasonal) • Persistent (perennial)

4. Non-allergic • Known cause: hormonal imbalance, infection, structural abnormality, rhinitis medicamentosa • Unknown cause (intrinsic): vasomotor

5. Allergic rhinitis: Classification • Seasonal vs Perennial – based on type of allergen and timing of symptoms • Seasonal AR = sensitized to outdoor allergens eg pollen • Perennial AR = sensitized to indoor allergens e.g. dust mites, animal dander • Symptoms often do not strictly adhere to classification • Patients allergic to perennial allergens have symptoms only for short periods • Pollination season highly variable among countries Ciprandi G, Cirillo I, Vizzaccaro A, et al. Seasonal and perennial allergic rhinitis: is this classification adherent to real life?. Allergy. 2005;60(7):882-887. doi:10.1111/j.1398-9995.2005.00602.x

6. Allergic rhinitis • Ig-E mediated, eosinophilic inflammation of the nasal mucosa in response to inhaled allergens in a sensitized individual • Characterized by sneezing, watery rhinorrhoea, nasal obstruction and itchiness • Allergens can be pollen, mould, animal dander, dust mites, cockroach residue • 30% of general population • Male = female • Parents smoking is an aetiological risk factor Agnihotri NT, McGrath KG. Allergic and nonallergic rhinitis. Allergy Asthma Proc. 2019;40(6):376-379. doi:10.2500/aap.2019.40.4251 Wise SK, Lin SY, Toskala E, et al. International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis. Int Forum Allergy Rhinol. 2018;8(2):108-352. doi:10.1002/alr.22073

7. Pathogenesis Early phase: 5-30min, due to release of vasoamine like histamine • Type I hypersensitivity. Inhaled allergen --- trigger plasma cells to produce IgE • Results in mast cell degranulation and the release of mediators such as histamine • Producing the typical symptoms of AR, including sneezing and mucus production • Late or delayed phase: 2-8 hrs. • The release of cytokines and chemokines from mast cells leads to recruitment of inflammatory cells such as basophils, lymphocytes, monocytes and eosinophils • Also release of mediators such as histamine and leukotrienes • Results in sustained nasal congestion and inflammation

9. CLINICAL PRESENTATION • Watery rhinorhea • Itchiness of nose, eyes, palate • Sneezing • Nasal congestion – Late phase associated with leukotrienes and PGD2 • Postnasal drip • Cough • Malaise Early phase due to histamine

10. Clinical features • Transverse nasal crest (salute sign) • Darken area under eyes , dennie- morgan lines(allergic shiner) • Adenoid facies in long standing AR –mouth breather • Redness of conjunctiva • Cold spatula test – unequal or reduced misting •  Swollen IT. Pale and edematous nasal mucosa. • Retracted TM, MEE • Granular pharyngitis --- hyperplasia of submucosal lymphoid tissue • Prolonged mouth breathing due to adenoid hyperplasia • Atopy: coexisting with asthma & eczema (an exaggerated IgE antibody response to aero-allergens)

11. Allergic rhinitis: Classification • ARIA- ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA (based on duration and severity) Min YG. The pathophysiology, diagnosis and treatment of allergic rhinitis. Allergy Asthma Immunol Res. 2010;2(2):65-76. doi:10.4168/aair.2010.2.2.65

12. Investigations • Allergic testing • SPT • serum IgE • nasal provocation test • Nasal smear– eosinophils • Nasal airway testing • peak nasal inspiratory flow • rhinomanometry

13. Allergic rhinitis: DIAGNOSTIC TESTS • In vivo - Skin tests – skin prick test, intradermal (intracutaneus) skin test • In vitro - Total/Specific IgE(RAST/Unicap/ImmunoCAP)

14. Skin prick test • Indications: Allergies, allergic rhinitis, asthma • Contraindications: Severe/unstable asthma, anaphylaxis, dermatographism • Advantages • Simple, rapid • Highly specific and sensitive • Inexpensive • Well tolerated Serum antigen specific IgE can be done in patients contraindicated for SPT

15. serum antigen Specific IgE • tIgE is frequently increased in AR, but inconsistent correlation with symptoms • Serum sIgE testing is asafe and effective option • Not subjective • No risk of anaphylaxis • Expensive

16. trEATMENT • 1) Allergen avoidance • 2) Medical • Intermittent mild AR Oral H1-antihistamine( cetirizine, loratadine, desloratadine, bilastine) or intranasal H1-antihistamine ( eg: azelastine) • and/or decongestant( eg:oxymethazoline) or  LTRA (Leukotrience receptor antagonist –eg:montelukast) • Intermittent moderate to severe AR Above + intranasal cortico-steroid( momethasonefuroate, fluticasone propionate, triamcinolone acetonide, etc)

17. Persistent mild •  Rx as intermittent mod-severe AR • Persistent mod to severe  Same as above If Rx failure, assess compliance, infection, and other causes. Consider short course steroid or decongestant for nasal block, add ipratropium bromide nasal spray 0.06% ( anticholinergic) for rhinorrhea/ nasal stuffiness, and antihistamine for itchiness Other medication Mast cell stabilizer --- sodium chromoglycate ( eg:intranasalchromolyn sodium) >Immunotherapy

18. immunotherapy • Allergen desensetization • Involves administering increasing doses of allergens to accustom the • body to substances that are generally harmless (pollen, house dust • mites) and thereby induce specific long-term tolerance. • Mode of administration: Sublingual vs subcutaneous • Indications: Patients • that are not well controlled by pharmacological therapy or avoidance measures • require high doses of medication, multiple medications, or both to maintain control of their disease • experience adverse effects of medications

20. 3) Surgical: persistent nasal block despite Rx • Inferior turbinate surgery • Turbinoplasty • Radiofrequency ablation • Submucosal diathermy • Turbinectomy • Septoplasty & FESS play little role, unless DNS or co-exist with rhinosinusitis

21. Definitions • Rhinosinusitis : Inflammation of nose and paranasal sinuses • Acute rhinosinusitis (ARS)- <4 weeks • Subacute rhinosinusitis -4 and 8 weeks • Chronic rhinosinusitis (CRS)- > 8 or 12 weeks • Recurrent acute rhinosinusitis (RARS)- ≥ 4 episodes per year with symptom free intervals

22. chronic RHINOSINUSITIS : Definition Chronic nflammation of the mucosa of nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either • nasal blockage/congestion • nasal discharge (anterior/posterior nasal drip) +/- >12 weeks • facial pain/pressure • reduction or loss of smell AND EITHER Endoscopic signs of: NASAL POLYPS and/or MUCOPURULENT DISCHARGE OR OEDEMA primarily from middle meatus CT changes: MUCOSAL CHANGES within the ostiomeatal complex and/or sinuses OR

23. Fokkens, Wytske J., et al. "Executive summary of EPOS 2020 including integrated care pathways." Rhinology 58.2 (2020): 82-111.

24. chronic RHINOSINUSITIS : risk factorS • Smoking • Asthma • Allergies esp certain phenotypes ie. AFRS, CCAD Association • GERD • Occupational exposure to dust, cleaning agents, poisonous gas • Obstructive sleep apnoea • Immune-deficiency Fokkens, Wytske J., et al. "Executive summary of EPOS 2020 including integrated care pathways." Rhinology 58.2 (2020): 82-111.

25. Chronic rhinosinusitis: classification by latest epos 2020 guidelines

27. History • Rhinorrhea • Nasal obstruction • Altered smell • Facial pain • Sneezing • Itching - eyes, throat, roof of mouth

28. Symptoms of infection • Facial pain • Discoloured, thick nasal discharge • Foul smelling nasal discharge • Fever Ear symptoms • Reduced hearing • Blocked ear • Otalgia

29. ENDOSCOPY findings

30. investigations • CT Paranasal sinus is the gold standard Indications - failed medical therapy - planned for surgery - atypical or severe disease to look for complication/other pathology • Allergy testing - coexisting allergy especially in certain subtypes of CRS

32. Treatment • The principal aims of treatment • 1)To correct the predisposing cause • 2) To ventilate the sinus and to restore normal mucosal lining in the sinus. • Generally, medical treatment should continue for at least three months before considering surgery.

33. mEDICAL TREATMENT • Saline irrigation --- Remove secretions, promote nasal mucosal healing • Oral & topical decongestants --- Reduce congestion & improve drainage • Antihistamines --- Decrease production of mucus & diminish rhinorrhea • Intranasal steroids --- Reduce inflammation & improve associated sx

34. 5) Antibiotics- should be reserved for: • Patients with severe symptoms regardless of duration • Patients with moderate to severe symptoms who meet criteria for clinical diagnosis of acute bacterial rhinosinusitis (symptoms lasting for > 7 days, including fever, maxillary facial/dental pain & purulent nasal secretions)  • Patients with complications

35. Surgical • Nasal polyps causing obstruction of most or all of nasal lumen • Sinus mucocele or pyocele • Fungal rhinosinusitis • Rhinosinusitis causing complications • Neoplasm or suspected neoplasm causing sinus obstruction •  Continued chronic and/or recurrent sinusitis despite appropriate medical • Recurrent sinusitis secondary to nasal polyposis • Correction of anatomic variations predisposing to chronic and/or recurrent • rhinosinusitis