Dr.med.dr.

Lukas Jusuf
Member of American Academy of Asthma Allergy and Immunology
Member of European Academy of Allergy and Clinical immunology
CCPG 2015 - RSPAD Gatot Subroto
Jakarta 19 20 September 2015
Definition

AR is allergen driven mucosal inflammation

AR must contain one or more of the following
symptoms:

Nasal congestion

Sneezing

Itching

Rhinorrhea

Postnasal drip
Allergic Rhinitis (AR)

IgE sensitization to an allergen by SPT or RAST

Associated symptoms :

Palatal pruritus

Pruritus of the ear canal

Ocular pruritus and watering

Anosmia or reduced sense of smell
Nonallergic Rhinitis (NAR)

Not mediated by IgE

Mucosal inflammation

Symptoms similar to AR , usually without itching

No sensitization to allergens
Nonallergic Rinitis WITH
Eosinophilia syndrome (NARES)

Symptoms are similar or identical to AR

No IgE sensitization to allergens

Eosinophils in nasal smear (may be > 20%)

Middle aged, paroxismal exacerbations

Increased risk for obstructive sleep apnoe
CLASSIFICATION

Seasonal AR

In one or more seasons, but not year round

Seasonal allergens: grass, trees, weeds

Perennial AR

Dust mites,molds, pet dander or insects

>2hours/day, >9 months out of the year

Episodic AR

Allergens sensitization occasionally
Pathophysiology

Ig E mediated reaction to environmental allergens

Mas cells degranulation

Preformed mediators: Histamine etc Immediate Response

Newly formed mediators : LTC4,LTD4,LTDE4 Late Pahase
Response (LPR)

Nasal congestion LPR

Priming occurs with prolonged allergen exposures-
inflammatory mediators continue to be released,
symptoms resolution may lag behind the decrease in
allegens (p0llen)

NAR causes: hormonal,vasomotor, medication induced
Risk Factors

Family history of atopy

Serum IgE > 100 IU/ml before age 6

Higher socioeconomic status

Presence of positive skin prick test (SPT)

First born children more likely

Environmental risk factors include smoke exposure
and allergen exposure in infancy
DIAGNOSIS

Common Symptoms : sneezing-rhinorrhea,postnasal
drip,nasal itching,congestion

Other symptoms: itching, of
palate,conjunctiva,throat, Eustachian tubes and
middle ear

Ear fullnes and popping

Pressure over cheeks-forhead

Occasionaly chronic cough

Particular trigger
Common comorbidities

Asthma

Obstructive sleep apnoe

Nasal obstruction from severe septal deviation

Inferior turbinate hyperthrophy

Adenoidal hyperthrophy

Refractory sinusitis

Allergic conjunctivitis
HISTORY

The most important step

Important elements:

Frequency of symptoms

Severity of symptoms

Relationship to past symptoms

Length of time symptoms appear after triggers
Triggers may be multiple
Where: home, school, work, .....
Home enviromental conditions
History

Medication

Aspirin, NSAID,oral contraceptives,ACE inhibitors, Beta
blocker

Current and past medication?
Family History of atopic diseases
Quality of life
Rhinorhea: clear !
Persistent, colored rhinorrhea >>> Sinusitis
Time frame : morning, seasonal,prennial
Physical Examination

Examine : head-eyes,ears,nose,throat

Unilateral-bilateral

Common findings:

Allergic salute Dennie,s lines-Conjunctivitis-allergic shiners

Turbinates : often edematous and pale

Cobblestoning in posterior oropharyng ->> postnasal drip

Check for otitis-Eustachian tube dysfunction

Check for septal deviation nasal polyps

Check heart and lung : wheezing

Check skin for Atopic dermatitis

If septal perforation is there :

Inappropiate use of INS (intranasal steroid)

Adverse effects of nasal medications

Intranasal narcotic abuse

Previous surgery

Systemic granulomatous disease
Differential Diagnosis

Vasomotoric rhinitis

Type of NAR-excessive vasomotor activity nasal
congestion

Mechanism not clear

Etiologies: odors,alcohol,spicy
foods,emotions,temperature change, bright lights

Drug induced rhinitis

ACE inhibitors, Beta blockers,ASA,NSAIDs, Oral
contraceptives, phosphodiesterase-5 selective
inhibitors,alpha receptor antagonist, cocaine
Differential Diagnosis

Hormonal Rhinitis

Type of NAR-hormone altering events nasal
obstruction and hypersecretion

Hypothyroidim, oral contraceptives, pregnancy

During second Trimester of pregnancy - disappear after
delivery

Rhinitis medicamentosa

Intranasal decongestants

Rebound congestion later nasal hypertrophy: beefy red
mucosa

Resolve after discontinuation of medicine
Differential Diagnosis

Nasal polyps
Lateral walls
Eosinophil-associated growth factors found in eosinophyl and
immuneglobulins they contain
If found in children , >>> Cystic fibrosis ?
Anatomic abnormalities
If Cerebrospinal fluid (CSF) rhinorrhea >>> Evaluate
with Beta-transferrin in nasal secretions
DIAGNOSTIC and Testing

Skin Prick Test and RAST (RadioAllergoSorbenTest)

Serum IgE Testing has 3 purposes :

Evidence of allergic basis

To confirm suspected allergens

To determine suspected sensitivity for avoidance
measure and/or immunotherapy

Allergens: trees,weeds, grasses,molds, perennial allergens
Laboratories

RAST Testing :

Sensitivity 70 75%

Performed if SPT can not be done :

Using antihistamine

Extensive skin disease

Uncooperative patients and children
Serum IgE and IgG subclasses are not used as diagnostic
tools for RA
 CT scan if anatomical abnormality or chronic sinusitis
suspected

Rhinoscopy :

Asses nasal passage structures

Evaluate for nasal polyps and sinusitis

Evaluate Vocal cords

Nasal Provocation Testing

If there is dicrepancy between history-SPT clinical
symptoms

Research
TREATMENT

When treatment with one class fails despite
compliance, substitution of another class should be
considered

If AR is mild, single agent therapy or combination
therapy may be used in addition to avoidance
measures

For all intranasal preparations, to spray medication
AWAY FROM THE SEPTUM to avoid irritation and
perforation.
MEDICATIONS

First Line

Intranasal steroids are the main stay of therapy.

Superior to all other medication choices for AR, because they
help prevent both early and late-phase responses.

Beclomethasone-Budesonide-Flunisolide-Fluticasone furoate-
Fluticason propionate-mometasone-triamcinolone-
ciclesonide

Adult dose is two sprays in each nostril daily

In seasonal AR at least 1 week before pollen season begin

Systemic side effects are minimal

Cave ! : nasalseptum trauma

Epistaxis if frequent then discontinue

Oral Antihistamine (AH)

They reduce symptoms of rhinorrhea,nasal
pruritus,sneezing,ocular pruritus and tearing

Less effective at reducing nasal congetion

Nonsedating second generation AH :Loratadine,
Desloratadine,Fexofenadine,Cetiricine, Levocetiricine
Nasal Antihistamines
As effective or superior to oral second-generation AH
Less effective than intranasal steroids
Examples: Azelastine and Olopatadine

Second line

Montelukast for seasonal and perennial AR

Intranasal cromolyn

Inhibits mast cell degranulation

Onset of action is 4 7 days

Effective for episodic AR

Must be used times daily for maximal effect

Is not as efficacious as nasal steroids or nasal antihistamines

Intranasal anticholinergic (ipratropium )

Reduces rhinorrhea

Not useful for nasal congestion

Side effects include epistaxis and nasal dryness

Use with caution in patients with glaucoma or prostate
hypertrophy

Nasal decongestant

Limited to < 5 days, otherwise Rhinitis medicamentosa

Examples : Oxiymethazoline and phenylephrine

Oral decongestant

Occasionaly useful in selected patients

Most products contain phenylephrine

Chronic use is not recommended
Oral Steroids
Rarely indicated in AR
For severe intractable nasal symptoms
Nasal polyps
5 7 days course

Immunotherapy

For perennial and seasonal AR when a specific allergen
has been identified

Successful rate 80%

Considered unsuccessful if no relief from symptoms
after 1 year maintenance therapy

Current recommendation suggest 3-5 years of therapy
Nonpharmacologic Therapies

Dust mite avoidance:

Cover for mattresses and pillows

Vacuum with HEPA filter

Wash linens in hot water

Indoor humidity <50% to avoid growth of fungi and dust mites

Hard surface flooring

Avoid contact with pets. HEPA filter room to confine pet allergen

Pollen counts :

highest on sunny,windy days with lower humidity

Close windows and doors during pollen season

Performing outdoor activities in the evening when pollen counts are
lower

Mold exposure avoidance:

Source of moisture should be avoided

Porous surface should be replaced

Eliminate cockroaches

Wear HEPA and pollen-proof face mask (N95) when
allergens cannot be avoided

Nasal salin irrigations may help symptoms of chronic
sinusitis
Special Considerations

Pregnancy

AR symptoms increased in one-third of pregnant patients

First- and second-generation antihistamines may be used.
Cetirizine is pregnancy class B medication

Oral decongestant should be avoided, particulary in the first
trimester

Intranasal Steroids (budesonide, beclomethason,fluticasone
propionate, class B), montelukast (Class B) and sodium
cromolyn (class B)

The already given Immunotherapy may be continued , but
not initiated
Special Considerations

Eldery Patients

Age related changes such as cholinergic hyperactivity,
anatomic changes or concomitant medication use may
affect rhinitis

Allergy is not common cause of new inset rhinitis in
person > 65 years

Intranasal steroids and ipratropium may be used safely

If antihistamines are used, nonsedating agents should
be chosen
Complications

Rhinosinusitis

Otitis media

Rhinitis medicamentosa

Psychological impact : depression, anxiety, low self-
esteem, shyness

Septal irritation or perforation as complication of
incorrect nasal steroid use
REFERRAL

To Allergist-Immunologist with multiple indication
which can increase compliance,quality of life,patient
satisfaction

Rhinitis with prolonged, severe disease and comorbid
conditions such as :

Asthma

Recurrent sinusitis

Nasal polyps

Complications occur
Systemic steroids for treatment
REFERRAL
Symptoms interfere with quality of life r ability to function
Current medication are:
Ineffective
Associated with adverse reactions
Multiple or costly over a prolonged period

Rhinitis medicamentosa has been diagnosed

Specific allergic triggere need identification
Inceased level of education is desired
Allergen imunotherapy is considered
More education is needed
Patient request consultation
Referral

Referral to otolaryngologist :

Nasal obstruction from severe nasal septal deviation
(septoplasty preffered overs ubmucosal resection)

Inferior turbinate hypertrophy

Adenoid hypertrophy

Nasal polyps which require removal

Complication from refractory rhinosinusitis (Functional
Endoscopic Sinus Surgery )
Monitoring/Follow Up

Clinical improvement better than the amount of
allergen concentration measurement

Assesment after 2 4 weeks after initiation of therapy

Single agent of intranasal steroids OR combination with
oral antihistamine

Oral antihistamine should be tried bevor leukotriene
inhibitors

Intranasal histamines and leukotrienes are more
appropriate for episodic AR

If one medication regimen does not seem to be effective,
addition of and agent or change to a different class