Dr Serge Maurice FRCSE
02 April 2008

Functions of the nose

To smell

To filter, warm and humidify the air we breathe

Some anatomical souvenirs

Noses come in various shapes or sizes

Allergic Rhinitis
Doctère, mo éna ène mari problème ek mo néné

Changes in Terminology

“OLD”: Seasonal & Perennial

“NEW”: Acute or Intermittent and
Chronic or Persistent (WHO 2000)

The Symptoms

Seasonal/Acute: Itching, Sneezing,
Rhinorrhea.

Perennial/Chronic: The blocked nose

The Acute Symptoms

The tingle

The itchy nose

The volley of sneezes

The flooding rhinorrhea

The ocular symptoms

The itchy palate

Acute symptoms: Sneezing &
Rhinorrhea

The Chronic Symptoms







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A blocked nose, often with hyposmia & hypoguesia
Recurrent bouts of AOM in kids
Otitis Media with effusion in kids and adults
The allergic salute
Recurrent bouts of acute sinusitis in adults
Chronic sinusitis and nasal polyposis
A nasal voice
Snoring and OSA in kids and adults

Chronic Symptom: Blocked nose

The allergic salute

Massive polyposis

The Culprits: Pollens

In the
Mauritian context, a frequently accused innocent: the sugar cane pollen

Flowers

Grasses and Trees

Moulds and Mites, Cockroaches

Pet animals

The Allergic Reaction

An Idiot’s Guide to the chain of reactions, from the first meeting to the divorce!

The first date -1
MACROPHAGE
ANTIGENS
The macrophage ingests the allergens, breaks them up and presents some of their chemicals to the immune cells, the lymphocytes

The first date -2
Lymphocyte
Plasmocyte
The lymphocytes send a message to the plasmocytes, that produce the antibodies
Antibodies
Mastocyte
The antibodies attach themselves firmly to the mastocytes(containing granules that intervene in the inflammatory reaction) and to basophils

The second date -1
The antigens this time link up to the antibodies attached to the mastocyte, and the latter is then activated

The second date -2
The activated mastocyte liberates its granules, that contain histamine and other inflammatory chemicals,(triptase, prostaglandins) responsible for the allergic reaction

ALLERGEN
The Start
ImmunoglobulinE (IgE)
Specially in the mastocytes
ALLERGIC
REACTION
Inflammatory Mediators
Cytokines

The Progression
Histamine
Leukotrienes
Cytokines, Interleukins
Neutral proteases
Immediate Reaction:
Acute Inflammation
Vasodilatation,oedema
Mucus++ Itching
Watery Rhinorrhea
Pruritus
Sneezing++++
Early Phase
Late Reaction:
Chronic Inflammation
Congested Mucosa
Obstruction, Infection
Blocked nose
Sinusitis
Pharyngitis
Otitis
Late Phase

Diagnosis





HISTORY: ALL IMPORTANT
Simple Rhinoscopy: Pale, boggy, bluish mucous membrane
Sometimes Polyps
Skin scratch tests and lab tests (RAST,
Phadiatop, Total IgE(inaccurate), nasal
IgE, nasal mucus eosinophils)-test food allergies in kids
Imaging NOT necessary for simple AR

Differential Diagnosis





Chronic Idiopathic Rhinitis (V.M.R)
NARES
Nasal hypersensitivity, specially to dust, perfume, tobacco smoke,SO2,NO2, cold air
Drug induced- Aspirin (Widal’s), ACE inhibitors, HRT, Methyl
DOPA,Reserpine
Last trimester of pregnancy

Treatment Principles

Acute/Intermittent/Seasonal
Symptoms

Chronic/Persistent/Perennial
Symptoms

Allergen Avoidance





If the allergen has been identified:
Avoid grass pollens
Get rid of offending pets
Treat pillows and mattresses
Avoid offending foods

But, unfortunately, more often than not, medication needed

Acute Symptoms

Local and Systemic decongestants

2 nd Generation Antihistamines, systemic and local

Local Steroids

Chronic Symptoms

Local and systemic steroids

2 nd Generation Antihistamines

Other drugs/measures

Other drugs/measures

Sodium Cromoglycate

Ipatropium Bromide (rhinorrhea)

SIT & SLIT

Leukotriene antagonists
(Zafirlukast, Montelukast)

Empirical dietary exclusion of cow’s milk and food additives (benzoates, nitrites, sulphites, colourings)

Specific Immunotherapy

Sublingual or injection

Should be reserved for mono/bi allergens (e.g. grass pollen & housedust mite)

NOT as first line, but if other measures useless

Injection method should only be done with resuscitative facilities available

Side-Effects -1

Early 2 nd G. antiH: (Astemizole,
Terfenadine..) : Liver and cardiac problems when used in association with some other drugs

Newer ones (fexofenadine, cetirizine, loratidine…):safe, but still cause drowsyness

Local acting (levocabastine, azelastine,): local irritation & unpleasant taste

Side effects -2

Local decongestants – abuse & R.M.

Systemic decongestants – glaucoma, prostate, HBP, palpitations, insomnia

Local Steroids sprays – Great, but local irritation, epistaxis & no effect on eye/palate itch

Cromoglycate – qds, hence poor compliance

Ipatropium – only on drip

Systemic Steroids??

Very useful in treatment of infective acute episodes (High Dose Short
Term)

BE VERY WARY OF THE DEPOT
STEROID INJECTIONS: Osteoporosis, muscle damage, diabetes, glaucoma, cataracts, gastric ulcers…

Some other helpful(?) measures

Saline douches

Petroleum jelly (Vaseline) application

Inhalations

Anti-oxidants (Vit C, E, Beta carotene, zinc, selenium…)

“Muco-regulators” (carbocisteine..)

To summarise:

The problem with allergies such as
Hay fever and Allergic Rhinitis is that it is considered to be a trivial and inconsequential disease. Symptoms such as runny nose, itchy eyes and nose with sneezing and blockage are obviously not life threatening, but affect up to 25% of the population and are the cause of significant disability and cost to society…/cont.

To summarise (cont)


Patients may also experience fatigue, irritability, as well as mood, cognitive and sleep disturbance in addition to the nasal, ocular and throat symptoms. Allergic rhinitis has important co-morbid associations such as chronic sinusitis, glue ear, asthma exacerbations, nasal polyps, sleep apnoea and dental malocclusion .
Dr A Morris, January 2007, Surrey Allergy
Clinic


Thank you for your attention