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The nasal passages are lined with a membrane that produces mucus Mucus is one of the body's defense systems: Thin clear liquid, traps small particles and bacteria The trapped bacteria usually remain harmless in healthy individuals Even under normal circumstances, this produces a cycle of congestion and decongestion that occurs continuously throughout the day When one side of the nose is congested, air passes through the open, or decongested, side. The sides alternate between being wide open and being narrowed

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More than 50 million Americans suffer from allergies Sixth leading chronic disease in U.S. 4.5 billion dollars in health care costs annually 3.8 million days lost yearly (from work and school)

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People with perennial allergic rhinitis, may experience sleep disorders and daytime fatigue. Often they attribute this to medication, but studies suggest congestion may be the culprit in these symptoms. Patients with seasonal allergies experience hundreds of brief, subtle awakenings, called "microarousals", each night. In such cases, people are not aware that they wake up, but such events can cause fatigue the next day.

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Children with severe allergies may have a higher risk for behavioral problems than those without allergies There have been reports that 30% to 45% of people with allergic rhinitis also suffer from ear infections (otitis media) Chronic nasal obstruction can affect a child's appearance. If a child can only breathe through the mouth, this might lead to an elongated face and an overbite from teeth coming in at an abnormal angle Chronic rhinitis can cause headaches and also affect a child's sleep, concentration, hearing, appetite, and growth

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Increasing age, atopy, and high socioeconomic status Parental history is also positively associated with development of allergic rhinitis. A maternal history of allergy was significantly associated with a diagnosis of rhinitis by age 6 years Other risk factors include indoor and outdoor air pollution

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Rhinitis develops when congestion becomes severe or other changes occur that irritate the nasal passage Patient must experience at least two of the following symptoms for an hour or more on most days: Runny nose Obstruction in the nasal passage Nasal itching Sneezing These symptoms may occur as a result of colds or environmental irritants, such as allergens, cigarette smoke, chemicals, changes in temperature, stress, exercise, or other factors

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When rhinitis lasts for a long period, it is most often caused by allergies but can also be caused by structural problems or chronic infections.

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Aging Process Mucous membranes become dry with age Cartilage supporting the nasal passages weakens, causing changes in airflow Therapy: Avoid possible allergens and airborne irritants and keep the nasal passages moist. Decongestants would not be appropriate

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Increased parasympathetic stimulation Overreaction to irritants, cigarette smoke, air pollutants, strong odors, alcoholic beverages, stress, and exposure to cold Gustatory rhinitis Not the same as allergic reaction

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Foreign Objects Blockage in young children is very often caused by foreign objects If left in place, they may eventually cause infection and nasal discharge, usually in one side of the nose, which may be yellow or green and foul smelling (very)

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One in five pregnant women will experience rhinitis symptoms (2 nd or 3 rd trimester) Hormonally induced Spontaneously resolves within few weeks after delivery Limited therapeutic options

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Medications and Illegal Drugs overuse of decongestant sprays can, over time (three to five days), cause inflammation in the nasal passages and worsen rhinitis, Rhinitis Medicamentosa Aspirin, Ibuprofen, and Naproxen Oral contraceptives, hormone replacement therapy, anti-anxiety agents, some antidepressants, and some blood pressure medications, including beta-blockers and vasodilators Sniffing cocaine damages nasal passages and can cause chronic rhinitis

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Patients demonstrate Allergic Rhinitis symptoms but without other systemic manifestations Negative SPT and negative RAST Diagnosis: Nasal provocation and detection of specific IgE in nasal mucosa

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Cystic fibrosis Mucociliary defects Cerebrospinal rhinorrhoea Anatomic abnormalities Foreign bodies Tumors Granulomas: Sarcoid, Wegeners, Midline Granuloma

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Polyps soft, fluid-filled sacs impede mucus drainage and restrict airflow develop from sinus infections, do not regress on their own and may multiply and cause considerable obstruction Deviated Septum A common structural abnormality that causes rhinitis When deviated, it is not straight but shifted to one side, usually the left

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Protrude from the sinuses into the nasal cavities, usually from the middle meatus Can be unilateral, or bilateral Anosmia, most common presentation Very common in CF 50% of children (4-16 y/o) w/ nasal polyps have CF

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Routinely ask for symptoms suggestive of asthma Perform chest examination Consider lung function testing Consider tests for bronchial hyperresponsiveness in selected cases

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Moderate- severe one or more items. abnormal sleep. impairment of daily activities, sport, leisure. abnormal work and school. troublesome symptoms Persistent. > 4 days per week. and > 4 weeks Mild normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms Intermittent. < 4 days per week. or < 4 weeks AR Classification in untreated patients

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Diagnosis is clinical Allergy Testing Skin testing and in-vitro blood testing Testing is important to institute specific avoidance measures Skin testing is slightly more sensitive Common allergens Outdoors: tree, grass, weed pollens, and mold Indoors: dust mites, pet dander, cockroaches and mold

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Skin prick test / positive result

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Nasal secretion / scraping cytology Nasal allergen challenge Nasal endoscopy CT scan anatomic abnormalities concomitant presence of sinusitis

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Immunoassay Not influenced by medication Not influenced by skin disease Does not require expertise Quality control possible Expensive Skin test Higher sensitivity Immediate results Requires expertise Cheaper Immunoassay vs skin test for diagnosis of allergy

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Imaging studies X-rays have a limited value CT scans are preferred for evaluation of sinusitis Endoscopy Usually performed by an ENT physician, allows easy evaluation of the nose, and throat areas

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The management of allergic rhinitis involves the following components: Allergen avoidance Pharmacotherapy. Allergen immunotherapy. Of note, immunotherapy helps prevent the development of asthma in children with allergic rhinitis, and thus should be given special consideration in the pediatric population.

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The most logical strategy for disease that relates to the indoor environment Effectiveness requires comprehensive and multifaceted measures More studies are needed to also address the role of indoor pollutants (e.g. NO 2, tobacco smoke, )

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Pets: If patient is allergic to pets, they should be given away or kept outside If this isn't possible, they should at least be confined to carpet- free areas outside the bedroom Cats harbor significant allergens, which can even be carried on clothing; dogs usually present fewer problems Washing animals once a week can reduce allergens. Dry shampoos, such as Allerpet, are now available for pets that remove allergens from skin and fur and are easier to administer than wet shampoos.

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Dust Control simply using a spray furniture polish is very effective for reducing both dust and allergens Air cleaners, filters for air conditioners, and vacuum cleaners with HEPA filters can help remove particles and small allergens found indoors Neither vacuuming nor the use of anti-mite carpet shampoo, however, is effective in removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergens Carpets and rugs should be avoided if possible

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Bedding and Curtains Using semipermeable coverings to fully encase mattresses, and pillows is the most proven effective step in reducing dust mite levels Curtains should be replaced with shades or blinds Bedding should be washed using the highest temperature setting

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Reducing Humidity in the House Dust mites thrive in humidity and damp houses increase the risk for mold On-going humidifiers, then, can be counterproductive. If they are used, humidity levels should not exceed 40% and they should be cleaned daily with a vinegar solution

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The newer second-generation antihistamines do not usually cause drowsiness to the extent that the first generation antihistamines do. Brand Names. Loratadine is approved for children age two and over. Cetirizine is the only antihistamine to date approved for infants as young as six months. Fexofenadine (Allegra) Studies suggest that cetirizine is more effective than either of these other agents in improving symptoms, including in children, although cetirizine causes more drowsiness at higher doses.

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Oral decongestants come in many brands, which mainly differ in their ingredients. The most common active ingredient is pseudoephedrine.

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Side Effects of Decongestants Agitation and nervousness. Drowsiness (particularly with oral decongestants and in combination with alcohol). Changes in heart rate and blood pressure. Avoid combinations of oral decongestants with alcohol or sedatives.

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Nasal corticosteroids reduction of symptoms and exacerbations reduction of mucosal inflammation reduction of late phase reactions priming nasal hyperresponsiveness 1 reduction of mucosal mast cells reduction of acute allergic reactions 2 suppression of glandular activity and vascular leakage induction of vasoconstriction 3

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Benefits: The most effective agents currently available for treating allergic rhinitis. Blocks the inflammatory response that triggers an allergic attack. They do not relieve symptoms immediately but may take several hours before their effects are felt. They reduce inflammation and mucus production. They improve night sleep and daytime alertness in patients with perennial allergic rhinitis. Beneficial in treating polyps in the nasal passages.

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Nasal corticosteroids Overall safe to use Adverse Effects Nasal irritation Epistaxis Septal perforation (extremely rare) HPA axis suppression (inconsistent and not clinically significant) Suppressed growth (only in one study with beclomethasone)

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Corticosteroids available in nasal spray form include the following: Beclometazone (Beconaze). Approved for children over six Mometasone furoate (Nasonex). Approved for use in patients as young as three. Fluticasone (Flonase). Approved for children over four. Budesonide (Rhinocort). Approved for children over six.

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sneezingrhinorrheanasalnasaleye obstructionitchsymptoms H1-antihistamines oral++++++0 to ++++++ intranasal++++++++0 intraocular0000+++ Corticosteroids+++++++++++ Cromones intranasal ++++0 intraocular0000++ Decongestants intranasal00++00 oral00+00 Anti-cholinergics0+++000 Anti-leukotrienes0+++0++ Medications for Allergic Rhinitis - ARIA

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Efficacious and equal to or superior to oral antihistamines for treatment of SAR Clinically significant effect on nasal congestion Improved nasal symptoms in patients who failed oral antihistamines Onset of action: 30 vs. 60-180 minutes for oral antihistamine Side effects: Sedation, bitter taste

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Azelastine Olopatadine (Patanase) Azelastine/Fluticasone (Dymista)

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Nasal glands are activated by muscarinic, cholinergic receptors Ipratropium bromide is a nonselective muscarinic receptor antagonist Ipratropium bromide applied intranasally blocks rhinorrhea induced by cholinergic stimulation Ipratropium bromide has negligent systemic anticholinergic activity Topical adverse effects: excessive dryness, epistaxis

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CysLT1 Receptor Antagonists Montelukast * Pranlukast * Zafirlukast 5-Lipoxygenase Inhibitors Zileuton * Approved for allergic rhinitis

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Anti-leukotriene treatment in allergic rhinitis Efficacy Equipotent to H1 receptor antagonists but with onset of action after 2 days Reduce nasal and systemic eosinophilia May be used for simultaneous treatment of allergic rhinitis and asthma Safety Dyspepsia (approx. 2%)

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Criteria for Allergen Immunotherapy Severity of rhinitis symptoms Duration of rhinitis symptoms Progression of rhinitis Failure to respond to medical treatment

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Administering Therapy Immunotherapy requires a prolonged course of weekly injections ("allergy shots"). The process generally follows this course: Injections of diluted extracts of the allergen are given on a regular schedule, usually weekly at first, then in increasing doses until a maintenance dose has been reached. It usually takes several months to reach a maintenance dose. At that time, intervals between shots can be two to four weeks, and the treatment is continued for up to three to five years. Patients can experience some relief within three to six months; if there is no benefit within 18-24 months, the shots should be discontinued.

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Not licensed to treat allergic rhinitis Could be considered in severe cases unresponsive to conventional treatment Could be an adjunct to immunotherapy in severe cases

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>4 years should be treated as for adults Children (>4) with AR and Asthma can be treated with combination of newer topical and inhaled corticosteroids Diagnosis in smaller children is difficult as can have up to 6 to 8 colds per year Small children oral antihistamines, saline sprays and corticosteroids if symptoms severe