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7/31/2019 allergic rhinitis and nasal polyps
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ALLERGIC RHINITIS
Dr Ravikumar MS(ENT)
Assoc Prof
Raichur Institute Of Medical Sciences
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Objectives
• Understanding what allergic rhinitis is
• How to recognize allergic rhinitis
• Treatment
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Definition
Allergic rhinitis (AR) = IgE mediated immunologicresponse of nasal mucosa to air borneallergens,characterised by
• Nasal congestion
• Nasal pruritis
• Rhinorrhea
• Sneezing
Nasal sx lasting > 1 hr on most days.
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Ages affected
• Not seen until after age 4 or 5.
– (Takes approx 3 pollen season exposures).
• 10-15% in adolescents (adolescents and
young adults).
• Peak age 30 (decades 2, 3 and 4).
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Predisposition
• Genetic:
– Positive FHx (polygenic inheritance)
– Negative FHx does not rule out dx of AR
• Atopic dermatitis:
– Early sign of predisposition to allergy.
• Previous exposure/environmental factors
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Comorbidities ass’d with AR
• Asthma
• Sinusitis
• Otitis Media (with effusion)
(AR occurs frequently in pts with asthma and
atopic dermatitis.)
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Types of Allergic Rhinitis
• Seasonal (intermittent sx)
• Perennial (chronic & persistent sx)
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Seasonal Rhinitis
• Pollen: – Spring = Trees
– Summer = Grass
– Fall = Weeds
• Mold:
– Spores in outdoors have seasonal variation(reduced #’s in winter, increased in
summer/fall due to humidity).• House dust mites:
– Generally a “perennial” allergen, but may beincreased in damp autumn months.
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Perennial Rhinitis• Fungi/mold:
– Exposure peaks accompany activities such asharvesting, cutting grass and leaf raking.
• Pet Dander (cats, dogs):
– Can linger up to 4 months after pet removal.
• House dust mites:
• Cockroaches: – Respiratory allergy
food allergens-
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Pathophysiology of Allergic Rhinitis
Source: Cumming’s Otolaryngology: Head & Neck Surgery
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Symptoms
Direct:• Nasal congestion
• Rhinorrhea
• Pruritis• Sneezing
• Eye tearing & pruritis
• Ear & palate pruritis
• Post nasal drip
• Anosmia
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Symptoms
Non-nasal:
• Sore throat
• Chronic cough
• Mouth breathing
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Symptoms
Psychosocial/Cognitive:• Fatigue
• Depression
• Irritability• Anxiety
• Sleep disturbance
• Poor concentration• Impaired learning, decision making and
psychomotor speed
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Diagnosis
• History
• Physical exam
• Skin prick testing, Nasal smear,
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History• General medical hx
• Rhinological sx – (environmental and/or occupational factors)
• Family Hx
• Frequency of sx – (daily, episodic, seasonal, perennial)
• Duration
• Severity (increased, decreased or same)
• Qualitate nasal discharge: – AR: clear and watery
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Physical exam
Nose
• Nasal mucosa classically pale blue, but not
diagnostic (60%).
• Thick yellowish secretions suggest
infection.
• Structural deformities that may impede air
flow (deviated nasal septum, nasal polypys,hypertrophied turbinates).
• “Allergic Salute”
• “Dennie-Morgan” line
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Eyes
• “Allergic Shiners”
• Conjunctivitis
• Tearing
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drtbalu's otolaryngology online 18
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Ears• Fluid
• Infection
Lungs
•Wheezing
• Persistent coughing
Other areas
• Stigmata of atopic diseases in conjunctionwith nasal sx:
– atopic eczema, asthma
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Skin Prick Testing
• IgE-mediated rxn (Type I).
• Small, but significant potentail for
anaphylactic rxn.• Wheal & flare response (15-20 minutes)
• Includes a “positive” and “control” soln.
• Positive rxn = over 3cm wheal with ass’d flare
and pruritis (no rxn to neg control).
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In vitro serum test (RAST)
• Radioallergosorbent test
• Serum levels of specific IgE antibodies.
• No longer performed• IMMUNOCAP – newer technology widely
performed
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Nasal smears
• Eosinophils may help differentiate “allergic”
from “infectious” rhinitis (neutrophils).
• Peripheral blood eosinophil counts
– does not assist in allergy diagnosis.
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Allergic Rhinitis
• Therapeutic options – Avoidance
– Intranasal steroids
– Antihistamines
– Decongestants
– Anticholinergics
– Cromolyn
– Leukotriene modifiers
– Systemic steroids
– Immunotherapy
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Antihistamines
First Generation
• diphenhydramine• Mechanism: inhibition of histamine (H1)
receptors.
• Effect: reduce sneezing, nasal pruritis andrhinorrhea, but not congestion.
• Side Effects: anticholinergic activity -->
adverse CNS effects.
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Antihistamines
Second Generation
• cetirizine, loratadine, fexofenadine• Mechanism: inhibit histamine (H1)
receptors.
• Effect: same as First generation.• Note:
– Nonsedating
• Topical preparation available
–Azelastine
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Decongestants (oral/topical)• i.e.: Oral
– Pseudoephedrine
– Phenylephrine• Topical
– More effective than systemic
– Oxymetazoline (0.05%)
– Phenylephrine (1%)
• Mechanism: alpha-adrenergic agonist.
• Effect: vasoconstriction
•Side effects: – Oral: HA, nervousness, irritability, tachycardia,
palpitations, insomnia.
– Topical(nasal): prolonged use (>5-7 days) leads torhinitis medicamentosa
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Corticosteroids (intranasal)
• i.e: Fluticasone, mometasone
• Mechanism:
• Effect: reduce nasal blockage, pruritis,
sneezing and rhinorrhea
C ti t id ( ti d)
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Corticosteroids (continued)Note: Fluticasone,mometasone
• most potent single medication for tx of AR.
• intanasal: acts locally.
• goal: control sx with lowest possible dose.
• >90% achieve symptomatic relief.
Side effects: nasal irritation, bleeding (nasal
septal perforation).
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Cromolyn Sodium (intranasal)
• Mechanism: mast cell stabilizing agent -->reduces release of histamine and othermediators.
• Effects: reduces nasal pruritis, sneezing,
rhinorrhea and congestion.
• Note:
– prophylactic use: start before pollinosis sx or
unavoidable/predictable exposures.• Side effects: locally, <10% of pts (sneezing,
nasal stinging, burning, irritation).
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Ipratropium (intranasal)• i.e.: Atrovent (intransal)
• Mechanism: inhibits muscarinic cholinergicreceptors.
• Effect: reduces watery rhinorrhea (no effect
on nasal itching, sneezing or nasalcongestion).
• Side effects: irritation, crusting, epistaxis.
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Leukotrine inhibitors
• Monteleukast – new medication
Equal in effectiveness to antihistamines
» Combination of monteleukast and an
antihistamine superior to each agent alone
All i Rhi iti
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Allergic Rhinitis• Therapeutic options
– Immunotherapy• Reserved for unavoidable allergens and inadequate response
to standard therapies
• Effects- Rise in serum-specific IgG
– Suppression of IgE
– Shift from TH2 to TH1 profile
– Reduction of inflammatory cells in the nasal mucosa and secretions
• Onset of action 12 weeks after starting therapy, increases slowly over 1-2 years
• Subcutaneous (SCIT)
– Antigen extract is injected into the skin
• Sublingual (SLIT) – Antigen is applied under the tongue
– Widely used in Europe
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NASAL POLYPI
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Definition
• The term polyp derived from Latin word
“Polypous” Many footed
• Defined as simple oedematous hypertrophic
nasal mucosa
• Can be unilateral / bilateral
34
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• Simple nasal polyp1
• Fungal polyp2
• Malignant polyp3
Classification
35
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Simple nasal polypi
• Also known as
inflammatory polyp
• Ethmoidal polyp
• Antrochoanal polyp
drtbalu's otolaryngology online 36
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Aetiology
• Chronic rhinosinusitis
• Asthma
• Autonomic nervous system dysfunction• Genetic predisposition
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Aetiology
• aspirin intolerance
• Cystic fibrosis• Allergic fungal sinusitis
• kartagener’s syndrome
• Young’s syndrome • Nasal mastocytosis
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Site of origin
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Examination
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Examination
• Smooth glossy multiple
mass seen in anterior
rhinoscopy• Insensitive on probing.
Probe can be passed
around the polyp
• Soft and mobile
drtbalu's otolaryngology online 42
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Malignant polypi
• Also known as sentinel polyp
• Caused due to mucosal oedema resulting
from the malignant tumor
• All nasal polypoidal mass removed from
elderly patients should be subjected to HPE
44
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45
/ l h f
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A/C polyp theories of
etiopathogenesis
• Proetz theory
• Bernoulli’s phenomenon
• Mucopolysaccharide changes
• Infections
46
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Bernoulli’s phenomenon
Pressure drop occurs next to the constriction.
This causes a suction effect pulling the sinus
mucosa into the nasal cavity.
48
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Mucopolysaccharide theory
• Proposed by Jakson
• Changes in the mucopolysaccharide present
in the ground substance causes nasal
polyposis
• These changes causes excessive water
retention causing swelling of nasal mucosa
which appears polypoidal
49
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Infection / inflammation
• Acinous mucous glands inside the antrum
gets blocked
• This forms a cystic lesion within the sinus
cavity
• This cyst gradually enlarges to completely fill
the antrum
• It exits via the accessory ostium to reach the
nasal cavity
drtbalu's otolaryngology online 50
R f t i i ti f AC
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Reasons for posterior migration of AC
polyp
• The accessory ostium is present posteriorly
• Inspiratory air current is more powerful than
expiratory current there by pushing the polyp
posteriorly
• The natural slope of nasal cavity is directed
posteriorly
• Cilia beats towards the choana
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P i
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Posterior
rhinoscopy
• Polyp can be seen atthe level of choana
• Antrochoanal polyp
can be seen exitingout of accessory
ostium
drtbalu's otolaryngology online 54
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Parts of antrochoanal polyp
drtbalu's otolaryngology online 55
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Differential diagnosis
• Meningocele
• Angiofibroma
• Sq cell carcinoma
• Enlarged turbinates
• Inverted papilloma
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Radiology
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Medical Management
• Antihistamines ?
• Nasal decongestant
• Steroids
• Antibiotics ?
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Treatment
• Traditional polypectomy
• Caldwel Luc procedure
• Microdebrider• Endoscopic sinus surgery
• Recurrence
– Multiple small polyps common – Large and antro-coanal less so
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AC polyp / Ethmoidal polypi
Ethmoidal polypi Antrochoanal polyp
Seen in adults Seen in children and adolescents
Allergy is the common cause Infection is the common cause
Multiple (bunch of grapes) Unilateral
Arises from ethmoidal labyrinth Arises from maxillary antrum
Seen easily on anterior rhinoscopy Seen commonly in post nasal exam
X ray PNS may show hazy ethmoids and
normal maxillary sinuses
X ray PNS shows hazy maxillary antrum
Mostly bilateral Usually unilateral
Recurrence is common Recurrence is uncommon
Polypectomy Caldwel luc surgery in recurrent cases
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