nasal obstruction and Allergic rhinitis

Differential Diagnosis of Rhinorrhea and
Nasal Obstruction
?Allergic Rhinitis
Seasonal/perennial/episodic or intermittent/persistent.
?Nonallergic Rhinitis
Perennial (vasomotor): Constant symptoms of profuse, clear
rhinorrhea and nasal congestion without correlation to specific
allergen exposure or signs of atopy.
Cold air–induced: Nasal congestion and rhinorrhea upon exposure
to cold, windy weather; occurs in both allergic and nonallergic
individuals.
Nonallergic rhinitis with eosinophilia syndrome (NARES): Most often seen in adults; characterized by eosinophilia on nasal
smears and with negative test results for specific allergens.
?Infectious Rhinitis
Bacterial, viral, fungal.
?Granulomatous Rhinitis
Sarcoidosis, Wegener’s granulomatosis.
?Drug-induced Rhinitis
Oral contraceptives, reserpine derivatives, topical decongestants (rhinitis medicamentosa),
?-blockers (eye drops).
?Mechanical Obstruction
Septal deviation:
Common, and might exacerbate nasal
obstruction in allergic rhinitis.
Foreign body:
Unilateral purulent nasal discharge is the usual manifestation of a foreign body and resolves after removal
Choanal atresia or stenosis: Bilateral choanal atresia is usually
diagnosed early in life, but unilateral choanal atresia or stenosis
can go unnoticed for several years. Easily diagnosed by nasal
endoscopy and axial computed tomography of the midfacial skeleton.
Adenoid hypertrophy:
Common cause of nasal obstruction in
children.
Others: Encephaloceles, lacrimal duct cysts, dermoids.
?Neoplastic Rhinitis
Benign: Polyps, juvenile angiofibroma, inverted papilloma.
Malignant: Adenocarcinoma, squamous cell carcinoma, lymphoma, rhabdomyosarcoma
.
Allergic rhinitis
Rhinitis if defined clinically by a combination of two or more nasal symptoms
Nasal obstruction…….blocking
Rhinorrhea…………...running
Itching and sneezing
Allergic rhinitis occur when these symptoms are the result of IgE mediated inflammation following exposure to allergen
Classification
Seasonal
Perennial
occupational
Allergic Rhinitis
Allergic rhinitis is a clinical hypersensitivity of the nasal mucosa to foreign substances mediated through IgE antibodies.
It has a prevalence of between 10% and 20% and affects 20 to 40 million individuals in the United States annually
The prevalence
Seasonal allergic rhinitis is higher in children and adolescents than in adults, and in childhood,boys outnumber girls.
the gender ratio becomes approximately equal in adults,
however, and may even favor women.
Because individuals require low-dose exposure to an offending allergen over many years before development of symptoms, seasonal rhinitis rarely occurs in children younger than 2 years
Most patients with allergic rhinitis have symptoms before age 20.
The severity of the disease remains relatively constant throughout childhood and early adulthood,
usually improves in middle age, and is seldom a problem in the elderly.
Atopy, the predisposition to respond to environmental
allergens with the production of specific IgE antibodies, occurs in
only 13% of children for whom neither parent is atopic, but in 29%
of children with one atopic parent or sibling and in 47% for whom
both parents are atopic
A history of asthma is also important, because allergic rhinitis is significantly more likely (up
to 4-6 times) to develop in individuals with asthma than in the general population
New classification by ARIA guideline (allergic rhinitis and its impact on asthma)
Mild
Normal sleep
Normal daily activities
Normal work and school
No troublesome symptoms
Moderate or severe
Abnormal sleep
Impairment of daily activities
Problems caused at school and work
Troublesome symptoms
Intermittent symptoms
Less than 4 days/week
Or less than 4 weeks
Persistent symptoms
More than 4 days/week and more than 4 weeks

Co-morbidities
Other conditions associated with allergic rhinitis are asthma,sinusitis,otitis media,sleep disorder,lower respiratory tract infection
Rhinitis and asthma are linked by epidemiological,pathophysiological characteristics and by common therapeutic approach.
?Rhinitis is a risk factor for the development of subsequent asthma ,
?is a frequent cause of asthma exacerbations ,and
?effective rhinitis treatment reduce asthma
So patient with persistent allergic rhinitis should be evaluated for asthma and the converse is true
Clinical presentation
Immediate type allergic symptoms of sneezing ,rhihinorrhea and itching are easily recognized

Perennial allergic inflammation is mainly expressed as nasal obstruction,hyperreactivity and poor sense of smell,the sinus lining is also usually involved so that the picture is of one of a chronic inflammatory rhinosinusutus,in those patient immediate symptom not present and may undergo unnecessary operations for septal deviation or turbinate befor the true nature of the problem is diagnosed properly!!!!
Examination
The mucosa appear pale, or bluish,boggy,swollen,NSD,polyp,inferior turbinate hypertrophy
Lab tests
1 skin prick test
2 serum IgE measurement either
RAST radioallergosorbant test
ELISA enzyme linked immunosorbant test
3 nasal cytology for eosinophil
4 nasal swab for bacterial and viral studies
5 nasal allergen challenge
Treatment
? identification and avoidance
? pharmacotherapy
Antihistamine
It relieve running,itching,and sneezing but have little or no effect on blockage
First generation like chlorpheneramine,diphenhydramines should be avoided because of sedation,psychomotor retardation and learning impairment because it cross the BBB and interact with histamine receptors
Second generation antihistamine act with an hour topical ones within 15 minutes
The newer non sedating antihistamines have few effects on Performance and a low reported incidence of sedation.
The second-generation antihistamines
include loratadine, cetirizine (both available over the
counter), desloratadine, fexofenadine, and, the latest, levocetirizine.
Both cetirizine and levocetirizine are labeled by the U.S. Food and
Drug Administration (FDA) as sedating, but they cause less sedation
than the first-generation antihistamines.
H1 antihistamines are also available for intranasal administration.
Azelastine, a phthalazinone derivative, is available in the United States for the treatment of allergic rhinitis. It is comparable in Efficacy of other antihistamines, is usually given twice daily
Terfenadine,astemazole block potassium channel and cause cardiac arrhythmia, QT prolongation,so care taken not overdose and nor to combine with erythromycin,ketokanazole,grapefruit juice,antiarrythmia .
Citrizine,fexofenadine,and desloratidine not block potassium channels even at supranormal dose
Desloratidine is exception that affect on nasal blockage
Topical corticosteroid
Are the most effective treatment of rhinitis especially if started prior to allergen exposure it reduce the relative risk of asthma exacerbation by 50%
Side effects are minor include epistaxis and nasal irritation Beclomethasone-------- Beconase
Budenoside--------------Rhinocort
Fluticasone -------------Floxanase
Sodium cromoglicate
It is weakly effective against all rhinitis but safe means it is useful for small children less than four years for whom a topical corticosteroid is not available
Decongestants
Used topically reduce nasal obstruction but increase rhinorrhea,regular use for more than few days result in rhinitis medicamentosa
Systemic decongestant are relatively ineffective with side effects like hyperactivity,insomnia in children and hypertension in adult
Decongestants
Both topical and systemic decongestants act by ?-adrenergic stimulation.
They cause vascular constriction and a reduction of both the nasal
blood supply and the volume of blood in the sinusoids. Topical decongestants,
which can be either catecholamines (such as phenylephrine)
or imidazoline derivatives (such as xylometazoline or oxymetazoline),
have a rapid onset of action and are usually more efficacious than
systemic decongestants. They do not have systemic side effects except
in children, in whom seizures have been reported. Continued use of
these agents leads to progressively shorter duration of action, until
almost continued application provides no relief—a condition known as rhinitis medicamentosa. Therefore, the use of topical decongestants
in allergic rhinitis should be limited to a short duration for the following
purposes: to? facilitate the penetration of intranasal steroids in
patients in whom severe congestion precludes it, ?to allow proper
physical examination, and ?to facilitate sleep during severe rhinitic
exacerbations.
Systemic decongestant
Pseudoephedrine hydrochloride and phenylephrine are
the most commonly used. They are used most frequently in combination preparations with antihistamines (pseudoephedrine)
or over the counter in cough and cold products in combination
with analgesics and antitussives. Phenylephrine is another
over-the-counter decongestant also used in combination products, but
a 2007 meta-analysis showed lack of efficacy for this agent on both
objective and subjective measures of nasal congestion in comparison with placebo. In addition to nasal vasoconstriction, oral decongestant cause vasoconstriction in other vascular beds, accounting for their
side effects, the most common of which are insomnia and irritability,
which can be seen in as many as 25% of patients
Ipratropium bromide
Response in patients who do not response to topical corticosteroid alone
Systemic corticosteroid
Used to unlock the nose at start of treatment or for sever symptoms,used for few days Depot injection not recommended because they are not stopped if side effects occur
Antileukotriens LRA
Recently been licensed in rhinitis it can also be helpful in polyposis
Leukotriene Modifiers
Because leukotrienes are generated in allergic rhinitis, the Effects of inhibitors of the 5-lipoxygenase pathway (zileuton) And leukotriens receptor antagonists (montelukast and zafirlukast) have been investigated.
By far the most commonly used agent in this category is,
Montelukast ,which is approved in the United States for the treatment of seasonal and perennial allergic rhinitis in adults and children
Anti-IgE
Recombinant, humanized, monoclonal anti-IgE antibody forms complexes
with free IgE and blocks its interaction with mast cells and
basophils. Anti-IgE has been shown to be beneficial
in the treatment of moderate to severe asthma, for which it is currently
indicated in the United States. Although it has also been shown
to be effective in decreasing nasal symptoms and improving quality
of life in patients with allergic rhinitis, the lack of cost-effectiveness as
well as the inconvenient route of administration (subcutaneous) make
this agent ill-suited as the mainstay of treatment of allergic rhinitis. In a clinical trial in patients with ragweed allergic rhinitis, anti-IgE
therapy was shown to enhance the safety of a rush (accelerated dosage
increase) immunotherapy regimen, allowing a significant reduction in
the time required for treatment
Immunotherapy
Allergen-specific immunotherapy involves the repeated administration,
sublingually or subcutaneously, of increasing doses of antigen extract
in an attempt to alter patients’ immunologic responses and improve
their symptoms. Immunotherapy is usually reserved for patients Who find it difficult to avoid allergens and who have not experienced adequade responses to pharmacologic It is alter the course of allergic disease and prevent the progression of allergic rhinitis to asthma .
session long as more as 2-3 years and should be given by trained personnel and only under medical observation
? Surgery
May play role especially when the main symptom is nasal obstruction.
Correction of NSD ,reduction of IT,surgery to improve nasal patency.
Nasal douching