Allergic Rhinitis

What is important for exam?

1)Short note on allergic rhinitis (Definition, types, etiology, clinical
features, management and complications)
Definition
• IgE mediated immune response of the nasal mucosa to air borne
allergens and is characterized by:
1)Watery nasal discharge
2)Nasal obstruction
3)Sneezing
4)Itching in nose

• Can also be associated with symptoms of itching in the eyes, palate

and pharynx
Clinical types
1)Seasonal
• Symptoms appears in or around a particular season

2)Perennial
• Symptoms present throughout the year
Etiology
1)Inhalant allergens
• Pollen from trees and grasses, mould spores, house dust, debris from
insects or house mite
• Food allergy is a rare cause

2)Genetic predisposition
• If 1 parent suffers from an allergic condition, there is a 20% chance
the child developing allergy
• If both parents  47% chance
 Inhaled allergen
Pathogenesis
Production of specific IgE antibody in genetically predisposed persons

Antibody fixed to basophils or mast cells by its Fc end

Subsequent exposure

Ag combine with Ig E antibody at its Fab end

Degranulation of mast cells with release of several chemical mediators

Vasodilatation, mucosal edema, infiltration of eosinophils, excess nasal

secretion or smooth muscle contraction
Allergic response occurs in 2 phases:
1)Acute or early phase
• Occurs immediately within 5-30 min after exposure to allergen
• Consists of sneezing, rhinorrhea, nasal blockage or bronchospasm
• Due to release of histamine

2)Late or delayed phase

• Occurs 2-8 hrs after exposure to allergen without additional exposure
• Due to infiltration of inflammatory cells eosinophils, neutrophils,
basophils, monocytes, CD4+ T cells causing swelling, congestion and
thick secretion
Symptoms
1)Sneezing 10-20 times at a time
2)Nasal obstruction
3)Watery nasal discharge
4)Itching of nose, eyes, palate, pharynx
5)Increased lacrimation
6)Hyposmia or anosmia
7)Decreased hearing due to ET block
Signs
1)Nasal signs
• A black transverse line across the middle of dorsum of nose due to
constant upward rubbing of nose (allergic salute)
• Turbinates are swollen
2)Ocular signs
• Edema of lids, congestion and cobblestone appearance of conjunctiva,
dark circles under the eyes (allergic shiners)
3)Otologic signs
• Retracted TM or SOM due to ET blockage
4)Pharyngeal signs
• Granular pharyngitis due to hyperplasia of submucosal lymphoid tissue
• Mouth breathing
5)Laryngeal signs- hoarseness and edema of vocal cords
Diagnosis
1)H/o and physical examination

2)TLC and DLC- eosinophila

3)Nasal smear for eosinophils

4)Skin tests- to identify specific allergen

5)Radioallergosorbent test (RAST)- in vitro test and measures specific IgE

antibody concentration in the patient’s serum

6)Nasal provocation test- a small amount of allergen is placed at the end of a

toothpick and patient is asked to sniff into each nostril to observe if allergic
symptoms are produced
Treatment
1)Avoidance of allergen

2)Treatment with drugs

i)Antihistaminics- chlorphenamine
ii)Sympathomimetics (oral or topical)
• Pseudoephedrine, phenylpronanolamine
• Phenylephrine, oxymetazoline, xylometazoline
iii)Corticosteroids
• Beclomethasone, fluticasone, mometasone
iv)Sodium cromoglycate- mast cell stabilizer (nasal drops, spray or aerosol powder)

3)Immunotherapy- when drug treatment fails or produces intolerable S/E

• Allergen is given in gradually increasing doses till maintenance dose is reached