DR.SUSHMITA PAL

@ theAurals: your ENT destination

Productivity i. Work/school days lost to absenteeismii. Days of reduced activity

Treatment expenses

Comorbid diseasesi. Sinusitisii. Asthma

Many patients have both AR and asthma

Upper airway symptoms of AR can exacerbate

asthma

AR patients without asthma often have bronchial

hyperactivity

Asthma leads to AR in 40 % cases

AR leads to asthma in 80 % of cases

Treatment of AR can improve asthma in many

patients

Treatment of AR can reduce the bronchial

hyperactivity

PATHOPHYSIOLOGYHISTORYTREATMENT

SYMPTOMS1. Headache2. Nasal --sneezing, pruritis, congestion,post

nasal drip , rhinorrhea3. Ocular–lacrymation, injection and

swelling of palpebral conjunctiva4. Aural – itching in ears, blocked ear,

diminished hearing

FREQUENCY o Seasonal rhinitis: trees, pollens, grass,

weedso Perennial rhinitis : pets , dust mite ,

animal dander, cockroaches , molds, fumes.

SEVERITYo Absence from work/schoolo Behavioral changeso Loss of smello Comorbid conditions

SEASONAL ARPERENNIAL AR

EYESEARSNOSEOROPHARYNXLUNGS

Mild intermittent Moderate severe intermittent Mild persistent Moderate severe persistent

INTERMITENT1. Less than 4 days in a week2. And , for less than 4 consecutive weeks

PERSISTENT1. More than 4 days a week2. AND, for more than 4 weeks

MILD When none of the following are present1. Sleep impairment2. Impairment in daily activities, leisure and/or sport3. Impairment of school or work4. Troblesome symptoms

MODERATE- SEVEREWhen one/more of the following are present1. Sleep impairment2. Impairment in daily activities, leisure and/or sport3. Impairment of school or work4. Troblesome symptoms

Upper respiratory tract infection

Chronic sinusitis

Anatomical nasal obstruction d/ti. Concha bullosaii. Nasal polypiii.DNSiv.Adenoid hypertrophy

Environmental control measures and avoidance of “allergens” or “triggers”

Pharmacological management

immunotherapy

Wash sheets in hot boiling water every week.Feathers, foam rubber, or pillows more than five years old are often allergens.Keep windows closed, so that there will not be so many pollens and molds in the houseWearing a mask when cleaning the houseRid your home of indoor plantsSleep with the head of bed elevated to relieve nasal congestionStop smokingObserve good health by exercising daily, eating balanced food and avoiding pollutants

H 1 antagonists : is the cornerstone of its treatment, for eg:CPM, Cetrizine, Loratidine, desloratidine, hydoxyzine, fexofenadine.

Mast cell stabilizers viz. Monteleukast, cromoglycate

Decongestants : oral or topical

Steroids : systematic and/ or topically

DEFINITION:Medical procedure that uses controlled

exposure to known allergens to reduce the severity of allergic disease.

Causes a rise in IgG “blocking” antibodies

ADVANTAGE OF IMMUNOTHERAPY: ADVANTAGE OF IMMUNOTHERAPY: prevent progression of rhinitis to asthma prevent progression of rhinitis to asthma

in children.in children. prevent onset of new sensitization in prevent onset of new sensitization in

allergic allergic patients.patients.

Subcutaneous and sublingual immunotherapy are the only approved routes of administration.

Subcutaneous immunotherapy normally involves a weekly subcutaneous injection of an extract of the allergen, in solution in increasing doses until a standard maintenance dose is reached.

This dose is then injected subcutaneously on a regular basis (at intervals of approximately 20 – 30 days) for not less than 2 years for perennial allergens.

1. Scratch test2. Prick test3. Intra cutaneous test

An immediate wheal & erythema is characteristic .

The tests are read after 20 minutes and are scored 0 to 4 depending on the size of the wheal & flare and the presence of pseudopod formation of the wheal.

Proven allergy with skin test or RAST Attempts to avoid allergens fail or

impractical Treatment with medicine is not fully

successful or when medication is not well tolerated.

Young patients without chronic irreversible changes in the upper airways

YES Poor response to

therapeutic trial Drastic

environmental changes are considered

NO History suggestive

for AR Trial of

appropriate therapy successful

Symptoms mild and easily managed

Mechanical, anatomical, or infectious causes

Pts with moderate severe symptoms ONLY, should be given nasal steroids

When should be a nasal decongestant used?

Should be AVOIDED to treat rhinitis as far as possible.

And if given, patient should be emphasized and explained …not to use it more than 5 – 7 days at a stretch….if possible explain its adverse effects and also the disease “rhinitis medicamentosa”.

In acute exacerbations of ALLERGIC RHINITIS….

ALLERGIC FUNGAL

RHINO - SINUSITIS

An allergic reaction to the aerosolized environmental fungi , especially , dematiaceous fungi( Alternaria,Fusarium, Chrysosporum), in an immuno competent host…

Whereas, invasive fungal rhinosisnusitis developes in immuno compromised pts.

Allergic (eosinophillic)mucin , mucostasis and thick fungal debris are found in the nasal and sinus cavities

AllergicAllergic mucin is the most reliable indicator for AFRS.It is thick , tenacious color ranging from tan to green , brown or black, with eosinophils and Charcot Leyden crystals. The mucin becomes more tenacious after treatment with steroids.

AFRS causing right proptosis,telecanthus and malar flattening.The position of eyes is notSymmetrical.Right nasal ala pushed inferiorly onLeft side