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Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish. Concord Rhinology, Allergy and Skullbase Surgical Unit. Evening Outline. Dr Arj Ananda Interpreting a CT scan of the sinus Dr Larry Kalish Allergic rhinitis - Diagnosis and Management Assoc Prof Ray Sacks - PowerPoint PPT Presentation
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Assoc Prof Ray SacksDr Arj AnandaDr Larry Kalish
Assoc Prof Ray SacksDr Arj AnandaDr Larry Kalish
Concord Rhinology, Allergy and Skullbase Surgical Unit Concord Rhinology, Allergy and Skullbase Surgical Unit
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Evening Outline Evening Outline
Dr Arj Ananda Interpreting a CT scan of the sinus
Dr Larry Kalish Allergic rhinitis - Diagnosis and
Management
Assoc Prof Ray Sacks Surgical management of Allergic Rhinitis
Dr Arj Ananda Interpreting a CT scan of the sinus
Dr Larry Kalish Allergic rhinitis - Diagnosis and
Management
Assoc Prof Ray Sacks Surgical management of Allergic Rhinitis
Allergic Rhinitis Diagnosis and Management
Allergic Rhinitis Diagnosis and Management
Dr Larry Kalish
MBBS (Hons I), MS, MMed(Clin Epi), FRACS
Concord Hospital ENT department
Sydney Sinus and Allergy Centre
Dr Larry KalishMBBS (Hons I), MS, MMed(Clin Epi), FRACS
Concord Hospital ENT department
Sydney Sinus and Allergy Centre
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Overview Overview
Definitions Epidemiology Unified airway Aetiology Diagnosis Investigations Management
Definitions Epidemiology Unified airway Aetiology Diagnosis Investigations Management
Definitions Definitions
Atopy inherited predisposition to produce IgE to environmental
allergens 40% of Australasian population is atopic All patients with allergic rhinitis are atopic
Allergic reaction exaggerated or inappropriate immune reaction which causes
damage to the host
Rhinitis = inflammation of the nose and sinuses Classified by aetiology
Allergic Non-allergic
Atopy inherited predisposition to produce IgE to environmental
allergens 40% of Australasian population is atopic All patients with allergic rhinitis are atopic
Allergic reaction exaggerated or inappropriate immune reaction which causes
damage to the host
Rhinitis = inflammation of the nose and sinuses Classified by aetiology
Allergic Non-allergic
Rhinitis - classification Rhinitis - classification AllergicNon-allergic
Infectious
Idiopathic or vasomotor Drug-induced (medicomentosa, OCP, cocaine, antihypertensives, NSAIDs etc)
Hormonal rhinitis of pregnancy, menstruation, menapause,
Endocrine Hypothyroidism, diabetes
Rhinitis of no airflowAtrophic - primary vs secondary Eosinophilic rhinitisOther systemic disordersTraumatic - thermal, chemical, physical
AllergicNon-allergic
Infectious
Idiopathic or vasomotor Drug-induced (medicomentosa, OCP, cocaine, antihypertensives, NSAIDs etc)
Hormonal rhinitis of pregnancy, menstruation, menapause,
Endocrine Hypothyroidism, diabetes
Rhinitis of no airflowAtrophic - primary vs secondary Eosinophilic rhinitisOther systemic disordersTraumatic - thermal, chemical, physical
AR - Epidemiology AR - Epidemiology
The prevalence of allergic rhinitis is increasing. Approximately 16% of Australians have allergic
rhinitis, including:
about 19% of working-aged adults about 25% younger adults (25–44 years) about 20% of adolescents (13–14 years) about 12.5% of primary school children (6–7 years)
Approximately 10% of all Australians and 14–16% of Australian children have asthma.
The prevalence of allergic rhinitis is increasing. Approximately 16% of Australians have allergic
rhinitis, including:
about 19% of working-aged adults about 25% younger adults (25–44 years) about 20% of adolescents (13–14 years) about 12.5% of primary school children (6–7 years)
Approximately 10% of all Australians and 14–16% of Australian children have asthma.
Rhinitis occurs in an estimated 75–80% of patients with asthma, with high rates reported in both atopic and non-atopic asthma.
Conversely, 20–30% of patients with known allergic rhinitis also have asthma.
Allergic rhinitis is now a recognised as a risk factor for developing asthma
Rhinitis occurs in an estimated 75–80% of patients with asthma, with high rates reported in both atopic and non-atopic asthma.
Conversely, 20–30% of patients with known allergic rhinitis also have asthma.
Allergic rhinitis is now a recognised as a risk factor for developing asthma
AR - Epidemiology AR - Epidemiology
Hygiene HypothesisHygiene Hypothesis
The most unifying hypothesis
= “Hygiene hypothesis”
Suggests that a Cleaner environment (eg less exposure to bacteria, use of vaccines and antibiotics etc) predisposes to the persistence of an allergic phenotype in early childhood
The most unifying hypothesis
= “Hygiene hypothesis”
Suggests that a Cleaner environment (eg less exposure to bacteria, use of vaccines and antibiotics etc) predisposes to the persistence of an allergic phenotype in early childhood
Unified Airway Theory Unified Airway Theory
The Nasobronchial Reflex, Sino-nasal protection of the lower airway Shared inflammation within a unified
airway
Aspiration of infected or inflammatory sinonasal secretions - UNSUPPORTED
The Nasobronchial Reflex, Sino-nasal protection of the lower airway Shared inflammation within a unified
airway
Aspiration of infected or inflammatory sinonasal secretions - UNSUPPORTED
AR - AetiologyAR - Aetiology
Inhaled AllergensInhaled Allergens
Particles which elicit an allergic response
Identified by their portal of entry via the respiratory tree which is richly supplied with IgE.
Essentially all inhalant allergy is IgE mediated, producing a Type I hypersensitivity reaction.
Particles which elicit an allergic response
Identified by their portal of entry via the respiratory tree which is richly supplied with IgE.
Essentially all inhalant allergy is IgE mediated, producing a Type I hypersensitivity reaction.
HypersensitivityHypersensitivity
Type I- Immediate Hypersensitivity Immediate Allergen binds 2 molecules of IgE Intracellular degranulation and
immediate release of products Ex. Allergic rhinitis, anaphylactic
shock, asthma
Type I- Immediate Hypersensitivity Immediate Allergen binds 2 molecules of IgE Intracellular degranulation and
immediate release of products Ex. Allergic rhinitis, anaphylactic
shock, asthma
From: kay: New England J of Medicine Vol 344(1). Jan 4, 2001. 30-37
Two PhasesTwo Phases
“Early Phase” response 10-30mins after allergen exposure Mast cells degranulate Vascular leakage / interstitial oedema
irritation of sensory nerves - Nasal pruritis, rhinorrhea, nasal congestion and sneezing
“Late Phase” response 4-8 hours later chemotaxis and migration of neutrophils, basophils,
eosinophils, T-lymphocytes, and macrophages across the mucosal endothelium into the nasal submucosa.
“Early Phase” response 10-30mins after allergen exposure Mast cells degranulate Vascular leakage / interstitial oedema
irritation of sensory nerves - Nasal pruritis, rhinorrhea, nasal congestion and sneezing
“Late Phase” response 4-8 hours later chemotaxis and migration of neutrophils, basophils,
eosinophils, T-lymphocytes, and macrophages across the mucosal endothelium into the nasal submucosa.
Allergens Allergens
Seasonals Pollens
Trees - ~ late winter - early spring Grasses - ~ summer Weeds - ~ end of summer / autumn
Perennials Dust mites Moulds - Alternaria, Aspergillus Cockroach allergens Dog and Cat dander
Seasonals Pollens
Trees - ~ late winter - early spring Grasses - ~ summer Weeds - ~ end of summer / autumn
Perennials Dust mites Moulds - Alternaria, Aspergillus Cockroach allergens Dog and Cat dander
AR - HistoryAR - History
If you don’t ask they won’t volunteer Classical Symptoms include
itchy eyes, nose, throat sneezing, BEWARE the reactive NOSE rhinorrhea, congestion,
Other symptoms headache, loss or diminished smell or taste, postnasal
drip, headaches, nocturnal cough, halitosis, mouth breathing, hoarse voice, sore throats and snoring.
Children Throat clearing in kids without nasal symptoms Allergic salute, nasal twitch Nocturnal cough, morning fatigue, “silent sleep apnea”
If you don’t ask they won’t volunteer Classical Symptoms include
itchy eyes, nose, throat sneezing, BEWARE the reactive NOSE rhinorrhea, congestion,
Other symptoms headache, loss or diminished smell or taste, postnasal
drip, headaches, nocturnal cough, halitosis, mouth breathing, hoarse voice, sore throats and snoring.
Children Throat clearing in kids without nasal symptoms Allergic salute, nasal twitch Nocturnal cough, morning fatigue, “silent sleep apnea”
Remember Remember
Patients can mistake symptoms of allergy for asthma
Classical symptoms common BUT not always present Watch out for rhinorrhea and blockage
alone
Patients can mistake symptoms of allergy for asthma
Classical symptoms common BUT not always present Watch out for rhinorrhea and blockage
alone
Onset, duration and pattern of symptoms over the day or year - see table
Family and personal history of allergic conditions, e.g. asthma, atopic dermatitis
Triggering and relieving factors Medications (including alternate
medications) Home, work and leisure environments Systemic symptoms (e.g. daytime fatigue).
Onset, duration and pattern of symptoms over the day or year - see table
Family and personal history of allergic conditions, e.g. asthma, atopic dermatitis
Triggering and relieving factors Medications (including alternate
medications) Home, work and leisure environments Systemic symptoms (e.g. daytime fatigue).
AR - HistoryAR - History
ClassificationClassification
Duration Symptoms
Intermittent
<4days / week OR < 4 weeks
Mild NORMAL SLEEP and minimal impairment of daily activities
Persistent
>4 days / weekOR >4 weeks
Mod-severe
ABNORMAL SLEEP or impairment of sport, leisure, work or troublesome symptoms
AR - Physical ExamAR - Physical Exam Nasal mucosa
pale/bluish, congested, boggy - covered by watery mucosa.
Eyes Dennie Morgan lines (Infraorbital oedema), allergic shiner /
lashes Other
Open mouth breathing, nasal crease, high arch palate, teeth crowding, posterior pharyngeal cobblestoning
Nasal mucosa pale/bluish, congested, boggy - covered by watery
mucosa.
Eyes Dennie Morgan lines (Infraorbital oedema), allergic shiner /
lashes Other
Open mouth breathing, nasal crease, high arch palate, teeth crowding, posterior pharyngeal cobblestoning
Be mindful of Be mindful of Unilateral nasal discharge
Purulent / bloody Foreign body until proven otherwise
Clear / straw colored CSF leak until proven otherwise
Unilateral nasal discharge Purulent / bloody
Foreign body until proven otherwise
Clear / straw colored CSF leak until proven otherwise
Nasal polyps
Difficult to treat eczema, food allergies or poorly controlled asthma
Persistent non-classical symptoms and signs for more than 12 weeks = Chronic CRS
Nasal polyps
Difficult to treat eczema, food allergies or poorly controlled asthma
Persistent non-classical symptoms and signs for more than 12 weeks = Chronic CRS
Be mindful of Be mindful of
AR - InvestigationsAR - Investigations
Allergy testing To confirm diagnosis To give avoidance advice Targeted immunotherapy
Indications Those patients who fail medical trial Identify those patients likely to
benefit from immunotherapy
Allergy testing To confirm diagnosis To give avoidance advice Targeted immunotherapy
Indications Those patients who fail medical trial Identify those patients likely to
benefit from immunotherapy
AR - InvestigationsAR - Investigations
Skin Prick (epicutaneous)RASTnasal provocation test total IgE
Skin Prick (epicutaneous)RASTnasal provocation test total IgE
RememberRemember
“Regardless of diagnostic test the clinical correlation with inhalant trigger is crucial”
Food allergies DO NOT cause allergic rhinitis Nasal sx in reaction to food is NOT allergy but
irritation or chemical intolerance
Rhinitis in response to fumes, temperature or climate change is NON-allergic
“Regardless of diagnostic test the clinical correlation with inhalant trigger is crucial”
Food allergies DO NOT cause allergic rhinitis Nasal sx in reaction to food is NOT allergy but
irritation or chemical intolerance
Rhinitis in response to fumes, temperature or climate change is NON-allergic
Management Management
Hayfever = asthma of the nose Hayfever = asthma of the nose
Patients need to appreciate this Patients need to appreciate this conceptconcept
AR - management AR - management
1. Allergen avoidance
2. Pharmacotherapy
3. Immunotherapy
4. Surgery
1. Allergen avoidance
2. Pharmacotherapy
3. Immunotherapy
4. Surgery
Multimodality treatment Multimodality treatment
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The Unified Airway: concepts and management: The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)Richard J. Harvey, Janet Rimmer, (in Press)
How can we get rid of Allergens?
How can we get rid of Allergens?
Don’t recommend unless allergen known to be significant contributor to symptoms
And does it work Level 4 evidence for most avoidance
techniques Dehumidifiers, A/C, acaracide sprays - no effect HEPA filter, mattress protectors, removal of carpet
Reduce allergen but NO clinical benefit in adults ONLY kids
Don’t recommend unless allergen known to be significant contributor to symptoms
And does it work Level 4 evidence for most avoidance
techniques Dehumidifiers, A/C, acaracide sprays - no effect HEPA filter, mattress protectors, removal of carpet
Reduce allergen but NO clinical benefit in adults ONLY kids
Allergen Avoidance Allergen Avoidance
Dust mites Encase mattress, box spring, and pillow in allergen impermeable
covers. Wash bed linens weekly in hot water >50oC (caution with potential
scalding in small children) Reduce clutter/toys/collections in bedroom Reduce indoor humidity to <50% Replace carpet with polished floor (ie, wood, vinyl) Replace upholstered furniture with leather, vinyl, wood, or plastic
or wash regularly Vacuum with high efficiency particulate air (HEPA) filters or dust
weekly with mask
Dust mites Encase mattress, box spring, and pillow in allergen impermeable
covers. Wash bed linens weekly in hot water >50oC (caution with potential
scalding in small children) Reduce clutter/toys/collections in bedroom Reduce indoor humidity to <50% Replace carpet with polished floor (ie, wood, vinyl) Replace upholstered furniture with leather, vinyl, wood, or plastic
or wash regularly Vacuum with high efficiency particulate air (HEPA) filters or dust
weekly with mask
Allergen avoidance Allergen avoidance Animal dander
Removal of animal from home If removal is not an option:
Keep animals outside or out of child’s bedroom Change and wash clothes after animal contact Use high-efficiency particulate air filters (eg, HEPA) Bathe animal 2 /week or weekly Wash cages or litter box frequently
Cockroaches Reduce cockroach food supply by encasing food and disposing of garbage
rapidly Restrict access (seal entry sources) Apply insecticides or exterminate professionally
Animal dander Removal of animal from home If removal is not an option:
Keep animals outside or out of child’s bedroom Change and wash clothes after animal contact Use high-efficiency particulate air filters (eg, HEPA) Bathe animal 2 /week or weekly Wash cages or litter box frequently
Cockroaches Reduce cockroach food supply by encasing food and disposing of garbage
rapidly Restrict access (seal entry sources) Apply insecticides or exterminate professionally
Allergen avoidanceAllergen avoidance
Indoor mold Eliminate damp areas and avoid high humidity Repair water leaks Clean moldy areas Limit house plants and exclude from bedroom Avoid humidifiers
ARE THESE MEASURES PRACTICAL ?
Indoor mold Eliminate damp areas and avoid high humidity Repair water leaks Clean moldy areas Limit house plants and exclude from bedroom Avoid humidifiers
ARE THESE MEASURES PRACTICAL ?
Minimize allergen loadMinimize allergen load
Regular nasal irrigation Normal saline irrigation
Aim to physically wash out allergens May improve drug delivery May improve mucociliary clearance
Regular nasal irrigation Normal saline irrigation
Aim to physically wash out allergens May improve drug delivery May improve mucociliary clearance
Drugs Drugs
Inhaled Nasal Corticosteroids
Antihistamines - topical and systemic
Anticholinergic sprays Leukotrienes Inhibitors Alpha-adrenergic agonists - decongestants Mast-cell stabilizer
Systemic and Intraturbinal Corticosteroid injections
Inhaled Nasal Corticosteroids
Antihistamines - topical and systemic
Anticholinergic sprays Leukotrienes Inhibitors Alpha-adrenergic agonists - decongestants Mast-cell stabilizer
Systemic and Intraturbinal Corticosteroid injections
DrugsDrugs
Preventers Inhaled Nasal Corticosteroids Mast-cell stabilizer Leukotrienes Inhibitors
Relievers Antihistamines - topical and systemic Anticholinergic sprays
Emergency Systemic Corticosteroids
Preventers Inhaled Nasal Corticosteroids Mast-cell stabilizer Leukotrienes Inhibitors
Relievers Antihistamines - topical and systemic Anticholinergic sprays
Emergency Systemic Corticosteroids
Drug treatment Drug treatment
Intranasal CorticosteroidsIntranasal Corticosteroids Mometasone (Nasonex) Fluticasone (Avamys, Becanase Allergy, Flixonase)
Bioavailability of <1% Better affinity to glucocorticoid receptor
Budesonide (Rhinocort) Beclomethasone (Becanase)
All no effect on HPA axis
Primarily block the late phase reaction. Only a small fraction is absorbed locally Side effects
Epistaxis 5-8%
Mometasone (Nasonex) Fluticasone (Avamys, Becanase Allergy, Flixonase)
Bioavailability of <1% Better affinity to glucocorticoid receptor
Budesonide (Rhinocort) Beclomethasone (Becanase)
All no effect on HPA axis
Primarily block the late phase reaction. Only a small fraction is absorbed locally Side effects
Epistaxis 5-8%
Antihistamines - oral Antihistamines - oral
Compete with Histamine for the H1 receptor. also change the three dimensional configuration of the receptor, decreasing its affinity
for histamine and down-regulating histamine-driven symptoms
Most effective when taken prophylactically
Non lipophilic second generation - do not cross the blood-brain barrier = minimal sedative effects.
Different classes may be more effective between differing individuals.
Most effective at reducing symptoms of sneezing, nasal itching, and rhinorrhea.
Compete with Histamine for the H1 receptor. also change the three dimensional configuration of the receptor, decreasing its affinity
for histamine and down-regulating histamine-driven symptoms
Most effective when taken prophylactically
Non lipophilic second generation - do not cross the blood-brain barrier = minimal sedative effects.
Different classes may be more effective between differing individuals.
Most effective at reducing symptoms of sneezing, nasal itching, and rhinorrhea.
Antihistamines - topical Antihistamines - topical
Levocabastine (Livositin) Azelastine (Azep)
RAPID onset Symptomatic relief DIAGNOSTIC in my practice
Occular preparations Livsotin / Azep Patanol - antihistamine + mast cell stabilizer
Levocabastine (Livositin) Azelastine (Azep)
RAPID onset Symptomatic relief DIAGNOSTIC in my practice
Occular preparations Livsotin / Azep Patanol - antihistamine + mast cell stabilizer
Other Management Options
Other Management Options
Surgery Turbinoplasty Vidian neurectomy Posterior neurectomy Septoplasty FESS
Immunotherapy Subcutaneous Sublingual
Surgery Turbinoplasty Vidian neurectomy Posterior neurectomy Septoplasty FESS
Immunotherapy Subcutaneous Sublingual
Immunotherapy Immunotherapy
Specific allergen immunotherapy Effective in the Mx of asthma and AR Can achieve durable remission of allergic sx May reduce risk of childhood allergy progressing to
asthma
Best given when there is evidence of AR predominantly due to single allergen
SLIT (sublingual) SCIT (subcutaneous)
Specific allergen immunotherapy Effective in the Mx of asthma and AR Can achieve durable remission of allergic sx May reduce risk of childhood allergy progressing to
asthma
Best given when there is evidence of AR predominantly due to single allergen
SLIT (sublingual) SCIT (subcutaneous)
SCIT SCIT
Subcutaneous injections Weekly to monthly for 2-3 yrs
Adverse effects Injection-site reactions Sneezing Bronchospasms Urticaria Anaphylaxis
Contraindicated Severe or ustable asthma or pts on Beta blockers
Subcutaneous injections Weekly to monthly for 2-3 yrs
Adverse effects Injection-site reactions Sneezing Bronchospasms Urticaria Anaphylaxis
Contraindicated Severe or ustable asthma or pts on Beta blockers
SLITSLIT
Self daily administration Relatively expensive
Limited but improving evidence Probably longer to work 3-5yrs SAFER
Self daily administration Relatively expensive
Limited but improving evidence Probably longer to work 3-5yrs SAFER
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The Unified Airway: concepts and management: The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)Richard J. Harvey, Janet Rimmer, (in Press)