allergiese rhinitis en co-morbiditeit · allergiese rhinitis vasomotoriese rhinitis poliepe •...
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ALLERGIESE RHINITIS EN CO-MORBIDITEIT
DR BEN VERMAAKDURBANVILLE
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SYSTEMIESE SIEKTE
ASTHMA
ALLERGIESERHINITIS
KOS ALLEGIE
DERMATITIS
KONJUNKTIVITIS
URTIKARIA
SYSTEMIESE SIEKTE
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LEWENSKWALITEIT
Loss of sleep (Simons, 1996)Daytime fatigue (Hudgel, 1994)Impaired concentration and learning (Marshall, 1993) Decreased productivity (Juniper, 1991)Reduced quality of life (Juniper, 1991)Increased occupational risk (Storms, 1997)
Simons FE. Allergy Asthma Proc. 1996;17:185-189.Hudgel DW. J Respir Dis. 1994;15:203-208.Marshall PS, Colon EA. Ann Allergy. 1993;71:251-258.Vuurman EF, van Veggel LM, Uiterwijk MM, et al. Ann Allergy. 1993;71:121-126.Juniper EF, Guyatt GH. Clin Exp Allergy. 1991;21:77-83.Storms WW. Allergy Asthma Proc. 1997;18:59-61.
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PROGRESSIE VAN ALLERGIE
0
4
8
12
16
3 13 23 33 43 53 63 73 83
ASTHMA
DERMATITIS
RHINITIS
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INTRODUCTION
Ig E mediated
Type 1 hypersensitivity
30% of population only 2% on medication
Intermittent (Seasonal)
Persistent (Perennial)
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HYPOTHESIS
Allergen
T-lymphocytes Mastcell
B- lymphocytes
Eosinophils
IL-4
VCAM-1
Chronic Rhinitis
Spesific Ig-E
Acute Rhinitis
IL-3, IL-5
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PATHOPHYSIOLOGY VAN ALLERGIE:TIPE I HIPERSENSITIVITEITS REAKSIE
TH2 = Type 2 helper T cell;IL = Interleukin; GM-CSF = Granulocyte-macrophage colony–stimulating factor; IgE = Immunoglobulin E.
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INVESTIGATIONS
• History and clinical evaluation• Skin prick testing• Rast - Phadiatop (inhalent allergy)
- Fx 5 (food allergy)• Pharmacia differential atopy test
– 96% sensitivity– 94% specificity– 95% reliability
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IDEAL SYSTEMIC ANTI-ALLERGICAND ANTI-INFLAMMATORY AGENT
• Potent antihistamine
• Broad anti-allergic– Mast cell stabilization– Inhibition of release of mast cell products (e.g.
prostaglandins, leukotrienes, histamine, tryptase, cytokines)
– Inhibition of release of basophil products (e.g. leukotrienes, histamine, cytokines)
– Inhibition of eosinophil migration and adhesion
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ANTI-HISTAMINES
• For sneezing, scratchy throat, itchy eyes• Will have little effect on nasal
congestion but may have drying effect• Sedating All cause sedation, some
drying, and possible urinary retention • Non-sedating more expensive.
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TOPICAL NASAL STEROIDS
• ‘Best allergy medicine going’• Make the nasal mucosa an inhospitable site
for mast cells• Blocks synthesis of both leukotrienes and
prostaglandins• Prevents influx of neutrophils
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Pre Rx Post Rx
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SYSTEMIC STEROIDS
• Principals for safe use:– Short term Rx (2 weeks)– Not more than every fourth month– Not instead but in addition to other basic
rhinitis medication– Not for children, pregnant woman or IDDM
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SYSTEMIC STEROIDS (CONTINUED)
• Intermediate acting– Prednisone– Methylprednisolone (Depo-Medrol)
• Long acting– Dexamethasone– Betamethasone (Celestone soluspan)
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ANATOMIE
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ANATOMIE
• 2 nasale holtes en 3 turbinate• vergroot nasale oppervlak en veroorsaak
turbilente lugvloei• middel meatus
- maksillêre antra- anterior ethmoidale- frontaal
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INLEIDING
• insidensie 135/1000
• impak op kwaliteit van lewe
• “medical outcome based study”
• dieselfde telling as pasiënte met angina & DOPS
• hoofrede vir antibiotika as voorskrif
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RHINOSINUSITIS
• definiesie“Sinusitis is not an entity in itself, but must be considered as an inflammatory disease invovlving the ostiomeatal complex, the nasal cavity, the nasopharynx and the upper and lower respiratory tracts”.Josephson, 1994
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HISTOLOGIE
• deel van die respiratoriese sisteem
• respiratoriese epiteel- vaskulêre, gesilieerde kolomagtige epiteel
• “Schneiderian membrane”
• bevat bekerselle en sero-musineuse kliere
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AETIOLOGIE
• viraal mees algemeenste voorloper• sinus obstruksie
- allergie- anatomie
• minder algemene oorsake- poliepe- mukosale edeem
- swangerskap- bloeddruk medikasie- antiosteoporose middels
• siliêre disfunksie- sistiese fibrose
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NASALE OBSTRUKSIE
• mukosaalakute bakterie/virus infeksieallergiese rhinitisvasomotoriese rhinitispoliepe
• struktureelseptum deviasieagar nasi selconcha bulosa
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INFEKTIEWE RHINITIS
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ALLERGIESE RHINITIS
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POLIEPE
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NASALE SEPTUM
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MIDDEL MEATUS
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SEPTALE SPUR
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AGGER NASI SEL
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CONCHA BULLOSA
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SIMPTOME EN TEKENS
• major- gesig
pyn/drukking/volheid- nasaal
obstruksie rhinorrhoea- postnasale drip- hiposmia/anosmia- koors (slegs in akute stadium)
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SIMPTOME EN TEKENS
• minor- hoofpyn- halitose- moegheid- tandpyn- hoes- oor
pyn/drukking/volheid
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DIAGNOSE
• klinies- gekiedenis- ondersoek
anterior rhinoskopiepharyngeale ondersoek
• beperkte waarde vir X-strale
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KLASSIFIKASIE
• akuut tot 4 weke 2 of meer major simptome/tekens1 major en 2 minor simptome/tekens
• subakuut <12weke
• akuut 4 of meer akute episodes per jaar
herhalend• chronies >12 weke
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BEHANDELING
• gehospitaliseerde pt.• immuun onderdruk• herhalende respiratoriese infeksie• AB in laaste 6 weke• chroniese infeksie• vermoed weerstandige organismeBeta-Laktaam Weerstandige Antibiotika
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KOMPLIKASIES
ORBITAALI preseptale swellingII orbitale sellulitisIII subperiostale absesIV orbitale absesV kaverneuse sinus trombose
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KOMPLIKASIES
INTRAKRANIALI meningitisII abses formasie
epiduraalsubduraalserebraal
III Trombophlebitissuperior sagitale sinus trombosekaverneuse sinus tombose
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ADJUVANTE RX
• hidrasie• sistemiese steroide - kontroversieel• lokale steroide• nie antihistamiene nie• nasale douche
- sout/koeksoda• simptomaties