Rhinitis

1. Rhinitis

2. What is Rhinitis? • The nasal passages are lined with a membrane that produces mucus • Mucus is one of the body's defense systems: • Thin clear liquid, traps small particles and bacteria • The trapped bacteria usually remain harmless in healthy individuals • Even under normal circumstances, this produces a cycle of congestion and decongestion that occurs continuously throughout the day • When one side of the nose is congested, air passes through the open, or decongested, side. The sides alternate between being wide open and being narrowed

3. Allergic Rhinitis, Facts More than 50 million Americans suffer from allergies Sixth leading chronic disease in U.S. 4.5 billion dollars in health care costs annually 3.8 million days lost yearly (from work and school)

4. Allergic Rhinitis:Effect On Quality of Life • People with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue. • Often they attribute this to medication, but studies suggest congestion may be the culprit in these symptoms. • Patients with seasonal allergies experience hundreds of brief, subtle awakenings, called "microarousals", each night. In such cases, people are not aware that they wake up, but such events can cause fatigue the next day.

5. Allergic Rhinitis:Effect On Quality of Life Children with severe allergies may have a higher risk for behavioral problems than those without allergies There have been reports that 30% to 45% of people with allergic rhinitis also suffer from ear infections (otitis media) Chronic nasal obstruction can affect a child's appearance. If a child can only breathe through the mouth, this might lead to an elongated face and an overbite from teeth coming in at an abnormal angle Chronic rhinitis can cause headaches and also affect a child's sleep, concentration, hearing, appetite, and growth

6. Allergic Rhinitis: Risk Factors Increasing age, atopy, and high socioeconomic status Parental history is also positively associated with development of allergic rhinitis. A maternal history of allergy was significantly associated with a diagnosis of rhinitis by age 6 years Other risk factors include indoor and outdoor air pollution

7. Sagittal view of the inside of the nasal cavity

8. Allergic Rhinitis: Mechanism

9. Allergic Rhinitis: Symptoms • Rhinitis develops when congestion becomes severe or other changes occur that irritate the nasal passage • Patient must experience at least two of the following symptoms for an hour or more on most days: • Runny nose • Obstruction in the nasal passage • Nasal itching • Sneezing • These symptoms may occur as a result of colds or environmental irritants, such as allergens, cigarette smoke, chemicals, changes in temperature, stress, exercise, or other factors

10. The Allergic Appearance: Allergic shiners related to chronic nasal congestion Mouth breathing and a gaping mouth

11. Chronic Rhinitis When rhinitis lasts for a long period, it is most often caused by allergies but can also be caused by structural problems or chronic infections.

12. Chronic Rhinitis Not Related to Allergies • Aging Process • Mucous membranes become dry with age • Cartilage supporting the nasal passages weakens, causing changes in airflow • Therapy: Avoid possible allergens and airborne irritants and keep the nasal passages moist. Decongestants would not be appropriate

13. Vasomotor Rhinitis: Chronic Rhinitis Not Related to Allergies Increased parasympathetic stimulation Overreaction to irritants, cigarette smoke, air pollutants, strong odors, alcoholic beverages, stress, and exposure to cold Gustatory rhinitis Not the same as allergic reaction

14. Chronic Rhinitis Not Related to Allergies Foreign Objects Blockage in young children is very often caused by foreign objects If left in place, they may eventually cause infection and nasal discharge, usually in one side of the nose, which may be yellow or green and foul smelling (very)

15. Rhinitis of Pregnancy One in five pregnant women will experience rhinitis symptoms (2nd or 3rd trimester) Hormonally induced Spontaneously resolves within few weeks after delivery Limited therapeutic options

16. Drug-Induced RhinitisChronic Rhinitis Not Related to Allergies Medications and Illegal Drugs overuse of decongestant sprays can, over time (three to five days), cause inflammation in the nasal passages and worsen rhinitis, Rhinitis Medicamentosa Aspirin, Ibuprofen, and Naproxen Oral contraceptives, hormone replacement therapy, anti-anxiety agents, some antidepressants, and some blood pressure medications, including beta-blockers and vasodilators Sniffing cocaine damages nasal passages and can cause chronic rhinitis

17. Local Allergic Rhinitis Patients demonstrate Allergic Rhinitis symptoms but without other systemic manifestations Negative SPT and negative RAST Diagnosis: Nasal provocation and detection of specific IgE in nasal mucosa

18. Conditions that mimic rhinitis Cystic fibrosis Mucociliary defects Cerebrospinal rhinorrhoea Anatomic abnormalities Foreign bodies Tumors Granulomas: Sarcoid, Wegener’s, Midline Granuloma

19. Chronic Rhinitis Not Related to Allergies • Polyps • soft, fluid-filled sacs • impede mucus drainage and restrict airflow • develop from sinus infections, do not regress on their own and may multiply and cause considerable obstruction • Deviated Septum • A common structural abnormality that causes rhinitis When deviated, it is not straight but shifted to one side, usually the left

20. Nasal Polyps • Protrude from the sinuses into the nasal cavities, usually from the middle meatus • Can be unilateral, or bilateral • Anosmia, most common presentation • Very common in CF • 50% of children (4-16 y/o) w/ nasal polyps have CF

22. Looking for asthma…

23. In Patients with Rhinitis: Routinely ask for symptoms suggestive of asthma Perform chest examination Consider lung function testing Consider tests for bronchial hyperresponsiveness in selected cases

24. Moderate-severe one or more items . abnormal sleep . impairment of daily activities, sport, leisure . abnormal work and school . troublesome symptoms AR Classification Intermittent . < 4 days per week . or < 4 weeks Persistent . > 4 days per week . and > 4 weeks Mild normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms in untreated patients

25. Allergic Rhinitis: Diagnosis • Diagnosis is clinicalAllergy TestingSkin testing and in-vitro blood testing • Testing is important to institute specific avoidance measures • Skin testing is slightly more sensitive • Common allergens • Outdoors: tree, grass, weed pollens, and mold • Indoors: dust mites, pet dander, cockroaches and mold

26. Allergy skin prick testing Skin prick test / positive result

27. Other diagnostic tests • Nasal secretion / scraping cytology • Nasal allergen challenge • Nasal endoscopy • CT scan • anatomic abnormalities • concomitant presence of sinusitis

28. Immunoassay vs skin test for diagnosis of allergy Skin test • Higher sensitivity • Immediate results • Requires expertise • Cheaper Immunoassay • Not influenced by medication • Not influenced by skin disease • Does not require expertise • Quality control possible • Expensive

29. Allergic Rhinitis: Diagnosis • Imaging studies • X-rays have a limited value • CT scans are preferred for evaluation of sinusitis • Endoscopy • Usually performed by an ENT physician, allows easy evaluation of the nose, and throat areas

30. Management of allergic rhinitis The management of allergic rhinitis involves the following components: • Allergen avoidance • Pharmacotherapy. • Allergen immunotherapy. Of note, immunotherapy helps prevent the development of asthma in children with allergic rhinitis, and thus should be given special consideration in the pediatric population.

31. Environmental control • The most logical strategy for disease that relates to the indoor environment • Effectiveness requires comprehensive and multifaceted measures • More studies are needed to also address the role of indoor pollutants (e.g. NO2, tobacco smoke, …)

32. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Pets: • If patient is allergic to pets, they should be given away or kept outside • If this isn't possible, they should at least be confined to carpet-free areas outside the bedroom • Cats harbor significant allergens, which can even be carried on clothing; dogs usually present fewer problems • Washing animals once a week can reduce allergens. Dry shampoos, such as Allerpet, are now available for pets that remove allergens from skin and fur and are easier to administer than wet shampoos.

33. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Dust Control • simply using a spray furniture polish is very effective for reducing both dust and allergens • Air cleaners, filters for air conditioners, and vacuum cleaners with HEPA filters can help remove particles and small allergens found indoors • Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergens • Carpets and rugs should be avoided if possible

34. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Bedding and Curtains • Using semipermeable coverings to fully encase mattresses, and pillows is the most proven effective step in reducing dust mite levels • Curtains should be replaced with shades or blinds • Bedding should be washed using the highest temperature setting

35. Allergic Rhinitis: TreatmentAvoidance/Indoor Protection • Reducing Humidity in the House • Dust mites thrive in humidity and damp houses increase the risk for mold • On-going humidifiers, then, can be counterproductive. If they are used, humidity levels should not exceed 40% and they should be cleaned daily with a vinegar solution

36. Allergic Rhinitis: Medical Treatment

38. Allergic Rhinitis:Second-Generation (Nonsedating) Antihistamines • The newer second-generation antihistamines do not usually cause drowsiness to the extent that the first generation antihistamines do. • Brand Names. • Loratadineis approved for children age two and over. • Cetirizineis the only antihistamine to date approved for infants as young as six months. • Fexofenadine (Allegra) • Studies suggest that cetirizineis more effective than either of these other agents in improving symptoms, including in children, although cetirizine causes more drowsiness at higher doses.

39. Allergic Rhinitis: Oral Decongestants Oral decongestants come in many brands, which mainly differ in their ingredients. The most common active ingredient is pseudoephedrine.

40. Allergic Rhinitis: Oral Decongestants • Side Effects of Decongestants • Agitation and nervousness. • Drowsiness (particularly with oral decongestants and in combination with alcohol). • Changes in heart rate and blood pressure. • Avoid combinations of oral decongestants with alcohol or sedatives.

41. 1 2 3 reduction of mucosal inflammation reduction of mucosal mast cells • suppression of • glandular activity • and vascular leakage • induction of • vasoconstriction reduction of late phase reactions priming nasal hyperresponsiveness reduction of acute allergic reactions Nasal corticosteroids reduction of symptoms and exacerbations

42. Allergic Rhinitis: Corticosteroid Nasal Sprays • Benefits: • The most effective agents currently available for treating allergic rhinitis. • Blocks the inflammatory response that triggers an allergic attack. They do not relieve symptoms immediately but may take several hours before their effects are felt. • They reduce inflammation and mucus production. • They improve night sleep and daytime alertness in patients with perennial allergic rhinitis. • Beneficial in treating polyps in the nasal passages.

43. Nasal corticosteroids • Overall safe to use • Adverse Effects • Nasal irritation • Epistaxis • Septal perforation (extremely rare) • HPA axis suppression (inconsistent and not clinically • significant) • Suppressed growth (only in one study with beclomethasone)

44. Allergic Rhinitis: Corticosteroid Nasal Sprays Corticosteroids available in nasal spray form include the following: Beclometazone (Beconaze). Approved for children over six Mometasonefuroate (Nasonex). Approved for use in patients as young as three. Fluticasone (Flonase). Approved for children over four. Budesonide (Rhinocort). Approved for children over six.

45. sneezing rhinorrhea nasal nasal eye obstruction itch symptomssneezing rhinorrhea nasal nasal eye obstruction itch symptoms H1-antihistamines oral +++ +++ 0 to + +++ ++ intranasal ++ +++ + ++ 0 intraocular 0 0 0 0 +++ Corticosteroids +++ +++ ++ ++ + Cromones intranasal + + + + 0 intraocular 0 0 0 0 ++ Decongestants intranasal 0 0 ++ 0 0 oral 0 0 + 0 0 Anti-cholinergics 0 +++ 0 0 0 Anti-leukotrienes 0 + ++ 0 ++ Medications for Allergic Rhinitis - ARIA

46. Nasal Antihistamines Efficacious and equal to or superior to oral antihistamines for treatment of SAR Clinically significant effect on nasal congestion Improved nasal symptoms in patients who failed oral antihistamines Onset of action: 30 vs. 60-180 minutes for oral antihistamine Side effects: Sedation, bitter taste

47. Nasal Antihistamines Azelastine Olopatadine (Patanase) Azelastine/Fluticasone (Dymista)

48. Anticholinergic treatment: ipratropium bromide • Nasal glands are activated by muscarinic, cholinergic receptors • Ipratropium bromide is a nonselective muscarinic receptor antagonist • Ipratropium bromide applied intranasally blocks rhinorrhea induced by • cholinergic stimulation • Ipratropium bromide has negligent systemic anticholinergicactivity • Topical adverse effects: excessive dryness, epistaxis

49. Anti-leukotriene agents CysLT1 Receptor Antagonists Montelukast * Pranlukast * Zafirlukast 5-Lipoxygenase Inhibitors Zileuton * Approved for allergic rhinitis

50. Anti-leukotriene treatment in allergic rhinitis • Efficacy • Equipotent to H1 receptor antagonists but with onset of action after 2 days • Reduce nasal and systemic eosinophilia • May be used for simultaneous treatment of allergic rhinitis and asthma • Safety • Dyspepsia (approx. 2%)