ENT - Allergic Rhinitis and Sinusitis

Allergic Rhinitis and Sinusitis

1. RHINITIS:

• Occurs most commonly as allergic rhinitis.
• Allergic and non-allergic rhinitis is classified as Noninfectious rhinitis.
• Allergic rhinitis is define as immunologic nasal response, primary mediated by immunoglobulin E (IgE)
• Non-allergic rhinitis is defined as rhinitis symptoms in the absence of identifiable allergy, structure abnormality or sinus disease. 

ALLERGIC RHINITIS 

• Defined as an inflammation of the nasal mucous, caused by an allerge
• Most comment atopic reaction.
• Affects 10% to 25% of the population.
• 50% of rhinitis in ENT is AR.
• Most commonly seen in young children and adolescents.

ETIOLOGY

• Classified as:
• precipitating factors
• predisposing factors  

PRECIPITATING FACTORS 

• Allergens present in the environment
• House dust and dust mites
• Feathers
• Tobacco smoke
• Industrial chemicals
• Animal waste
• Disturbances in normal nasal cycle

PREDISPOSING FACTORS

• Puberty
• Pregnant states and postpartum stages
• Menopausal
• 50% of allergic rhinitis patients have a positive family history of allergic rhinitis
• Psychological: Focal sensitivity states
• Infection: fungal infections
• Age and sex
• IgA deificiency

COMMON ALLERGEN

• Pollens
• spring tree pollen's (maple alder,birch)
• Summer : grass pollent (bluegrass,sheep, shorell etc)
• Autumn: weed pollent(ragweed)
• Insects
• Cockroaches,house,files,fleas,bed bugs,

• Animals
• Cats,Dogs,Horse, monkeys,Rats,Rabbits etc
• Dust mite
• Dermatophagoides,Ingestants,nuts,fish,eggs,milk etc

PATHOPHYSIOLOGY

• Immunoglobulin (Ig) E mediated type 1 hypersensitivity response to an antigen ( allergen) in a genetically susceptible person.
• Type 1 Hypersensitivity causes local vasodilatioon and increase capillary permeability.

CLASSIFICATION

• Intermittent
• Symptoms present less than 4 days per week and less than 4 weeks per year
• Persistent
• Symptoms present more than 4 days per week and more than 4 weeks per year

COMPLICATIONS

• Allergic asthma
• Chronic otitis media
• Hearing loss
• Chronic nasal obstruction
• Sinusitis
• Orthodontic malocclusion in children

SIGN AND SYMPTOMS

• Sneezing
•  Rhinorrhoea
• Headache
• Tearing of eyes
• Swollen eyes
• Drowsiness
• Itchy nose, ears, eyes and palate
• Post nasal drip
• Read eyes
• Anosmia
• Fatigue
• Malaise

PHYSICAL EXAMINATION

• Nasal crease
• Horizontal crease across the lower half of the bridge of the nose
• Rhinorrhoea
• Thin watery secretions
• Deviated or perforated nasal septum

EXTRA NASAL MANIFESTATIONS

• Retraced and abnormal flexibility of TM
• Inflammation and swelling of the papebral conjunctiva with excess tearing
• Cobblestone appearance on oropharynx

CLASSICAL SIGNS

• Over bite 
• High arched palate
•  Allergic shiners
• Allergic salute
• Transverse crease over tip of nose and lower eye lid
• Conjunctiva congestion
• Periorbital oedema

INVESTIGATION

• History
• Histamine test
• Nasal smear
• Intranasal provocation test 
• Skin tests
• Nasal cytology
• RAST ( radio allergo sorbant test)
• FAST ( fluro allergo sorbant test)
• PRIST( paper immuno allergo sorbant test)
• Xray PNS
• CT PNS (for complicated cases with polyposis)
• Nasal endoscopy ( under local or GA)
• Evaluate for asthma

MANAGEMENT

• AVOIDANCE

• Minimize contact with offending allergens
• Reduce dust mite exposure by encasing bed
• Pillows and mattresses in allergen proof covering
• Use of allergen proof bedding

ACUTE PHASE MEDICATIONS

• Antihistamines
• Decongestants
• Anticholinergenic agents
• Inhibit mucous secretions,act as drying agent
• Topical eye preparations
• Reduce inflammation and relieve itching and  burning
• Oral mast cell stabilizer
• Intranasal corticosteroids
• Leukotriene receptor antagonists
•  Montelukast and Zafirlukast

SURGICAL THERAPY

• Submucosal turbinectomy- reduces size of boggy turbinates
• Septoplasty- correction of deviation of the septum
• Sinus surgery- Clearance of simuses if sinusitis is present

2. SINUSITIS