Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish
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Transcript Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish
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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
Surgical management of Allergic Rhinitis
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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
Overview
Definitions
Epidemiology
Unified airway
Aetiology
Diagnosis
Investigations
Management
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
Allergic
Non-allergic
Rhinitis - classification
Infectious
Idiopathic or vasomotor
Drug-induced
(medicomentosa, OCP, cocaine, antihypertensives, NSAIDs etc)
Hormonal
rhinitis of pregnancy, menstruation, menapause,
Endocrine
Hypothyroidism, diabetes
Rhinitis of no airflow
Atrophic - primary vs secondary
Eosinophilic rhinitis
Other systemic disorders
Traumatic - thermal, chemical, physical
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.
AR - Epidemiology
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
Hygiene 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
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
AR - Aetiology
Inhaled 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.
Hypersensitivity
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 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.
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
AR - 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”
Remember
Patients can mistake symptoms of allergy for
asthma
Classical symptoms common BUT not always
present
Watch out for rhinorrhea and blockage alone
AR - History
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).
Classification
Duration
Symptoms
Intermitte
nt
<4days / week
OR
< 4 weeks
Mild
NORMAL
SLEEP and
minimal
impairment of
daily activities
Persistent
>4 days / week
OR
>4 weeks
Modsevere
ABNORMAL
SLEEP or
impairment of
sport, leisure,
work or
troublesome
symptoms
AR - 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
Be mindful of
Unilateral nasal discharge
Purulent / bloody
Foreign body until proven otherwise
Clear / straw colored
CSF leak until proven otherwise
Be mindful of
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
AR - 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
AR - Investigations
Skin Prick (epicutaneous)
RAST
nasal provocation test
total IgE
Remember
“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
Hayfever = asthma of the nose
Patients need to appreciate this concept
AR - management
1. Allergen avoidance
2. Pharmacotherapy
3. Immunotherapy
4. Surgery
Multimodality treatment
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The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)
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
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
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
Allergen 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 ?
Minimize allergen load
Regular nasal irrigation
Normal saline irrigation
Aim to physically wash out allergens
May improve drug delivery
May improve mucociliary clearance
Drugs
Inhaled Nasal Corticosteroids
Antihistamines - topical and systemic
Anticholinergic sprays
Leukotrienes Inhibitors
Alpha-adrenergic agonists - decongestants
Mast-cell stabilizer
Systemic and Intraturbinal Corticosteroid injections
Drugs
Preventers
Inhaled Nasal Corticosteroids
Mast-cell stabilizer
Leukotrienes Inhibitors
Relievers
Antihistamines - topical and systemic
Anticholinergic sprays
Emergency
Systemic Corticosteroids
Drug treatment
Intranasal 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%
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.
Antihistamines - topical
Levocabastine (Livositin)
Azelastine (Azep)
RAPID onset
Symptomatic relief
DIAGNOSTIC in my practice
Occular preparations
Livsotin / Azep
Patanol - antihistamine + mast cell stabilizer
Other Management Options
Surgery
Turbinoplasty
Vidian neurectomy
Posterior neurectomy
Septoplasty
FESS
Immunotherapy
Subcutaneous
Sublingual
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)
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
SLIT
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: Richard J. Harvey, Janet Rimmer, (in Press)