Allergic Rhinitis

I MADE SUDIPTA
Dept of Otorhinolaryngology Head &
Neck Surgery

INTRODUCTION
AR Atopic disease which is often found in
clinical practice
It is a manifestation from type I hypersensitivity
based on Gell & Comb classification. IgE
mediated nasal mucosa as target organ

Affected all age, especially children, teenager

and young adult (productive ages)

Recurrence , disturbed daily activity and

family
Patient has difficulty to concentrate, head
ache, sleep disturbance, emotion
disturbance, frequent sneezing

Decreased productivity in worker, added

expenditure for doctor and medicine

Definition
Allergic rhinitis is an inflammation process in
mucous membranes of the nose which is
mediated by Ig E. This reaction is due to
abnormal reaction / hypersensitivity of
nasal mucosa to specific allergen.
For normal people this process doesnt
cause any reaction

Etiology
Allergen :
1. Inhalant : house dust, pollen, animal
dander, etc
2. Ingestion : Milk, shrimp, egg, peanuts
3. Injection
4. Contact

Pathophysiology
If someone ingested [ oral, inhalation ] or
injected with allergen, in several minutes
Immune response with production
of antibody or immunoglobulin
Immunoglobulin will react to that allergen
immunity or allergy
[hypersensitivity ]

In Immunity, Immunoglobulin will protect our

body from occurrence of disease.
but
In allergy, Immunoglobulin will cause our
body to suffer from disease.
In mucosa and blood circulation of patient,
there is specific Ig which can only give
reaction to certain allergen

This allergy reaction will degranulate mast cells and/or

basophils
releasing of vasoactive amines such
as:
histamine
bradykinine
serotonin etc

Histamine and Serotonin :

Dilatation & Increase permeability of capillary blood
vessels
Smooth muscle contraction
Increase secretion of lacrimal gland, bronchus and
digestive tract

Bradykinine :
Smooth muscle contraction
Increase permeability of capillary blood
vessels
vasodepressor decrease blood pressure
Increase secretion of salivary gland and
sweat gland

This process will end if contact with

specific allergen is also discontinued

Classification
Based on time of exposure and type of
allergen
Seasonal : present during certain season
Perennial : present throughout the year and
do not affected by season

New classification of AR by WHO ARIA

( Allergic Rhinitis and Impact on Asthma )
2007
Based on :
1. Intermittent if
* <4 days per week
* or <4 weeks
2. Persistent if
* >4 days/week
* and >4 weeks

Based on severity :
Mild all of the following
normal sleep

no impairment of daily activities, sport, leisure

no impairment of work and school
no troublesome symptoms
Moderate-Severe one or more items
abnormal sleep

impairment of daily activities, sport, leisure

impaired work and school
troublesome symptoms

ARIA Classification

Intermittent

Persistent

. < 4 days per week

. or < 4 weeks

. 4 days per week

. and 4 weeks

Mild
normal sleep
no impairment of daily
activities, sport,
leisure
normal work and
school
no troublesome
symptoms

Moderatesevere
one or more items

. abnormal sleep
. impairment of daily
activities, sport, leisure
. abnormal work and school
. troublesome symptoms

Sign & Symptoms

- Itchy at the nose, ear and soft palate

- Frequent sneezing
- Nasal blockage
- Clear and watery runny nose
- Nasal mucosa: edema, pale or bluish

 Allergic shiners are the dark discoloration of the

lower eyelids which occurs due to venous stasis

in individuals with chronic nasal congestion
Allergic salute, due to itching, patient often rubs

his/her nose using the back of the hand

Allergic crease, a horizontal crease or pale line

that develops across the lower part of the nose

as a consequence of frequent upward wiping of
the nose.

Allergic Salute

Allergic Shiner

Allergic Crease

Adenoid Facies

Ancillary procedure
1.

Skin test :
Single Intracutan or intradermal or serial [ Skin End-point
Titration ]
Prick Test
Scratch Test

2.

Nasal mucous cytology for eosinophilia

3.

Ig E specific test [ Radioallergosorbent test /RAST ]

4.

Paranasal sinus X-Ray [ Water`s ]

5.

Elimination and provocation test [ for food allergy ]

Management
1. Contact avoidance with allergen
2. Medicine

- anti histamine
- decongestant
- antihistamine + decongestant
- corticosteroid
3. Immunotherapy
4. Increase body resistance with: exercise,
good nutrition and enough rest

ELIMINASI ALERGEN/ AVOIDANCE

Differential diagnose :
1. Acute Rhinitis.
2. Rhinitis medicamentosa.
3. Vasomotor Rhinitis