allergic rhinitis Flashcards
an inflammatory disorder of the nasal mucosa
marked by nasal congestion, rhinorrhea, and itching, often accompanied by sneezing and conjunctival inflammation
allergic rhinitis
recognition as a major chronic respiratory disease of children rests largely on its high prevalence
detrimental effects on quality of life and school performance, and comorbidities.
Children with AR often have related
conjunctivitis, sinusitis, otitis media, serous otitis, hypertrophic tonsils and adenoids, and eczema
Childhood AR is associated with a ___ increase in risk for asthma at an older age.
3-fold
In prosperous ___ societies of children suffer from AR
20-40%
The symptoms may appear in infancy; with the diagnosis generally established by the time the child reaches age
6 yrs
The prevalence peaks early in childhood.
false late
Risk factors of allergic rhinitis family history of atopy and serum immunoglobulin (Ig) E higher than ___
100 IU/mL before age 6 yrs
late life exposures and/or their absence have a profound influence on the development of the allergic phenotype.
false- early
The risk increases in children whose mothers smoke heavily, even before delivery and especially before the infants are
1 yr old
The risk increases in children with
heavy exposure to indoor allergens
A critical period exists early in infancy when the genetically susceptible individual is at greatest risk of
sensitization
delivery by _____ is associated with AR and atopy in children with a parental history of asthma or allergies
caesarean section
cesarean section delivery association may be
explained by the
lack of exposure to maternal vaginal/fecal flora during
delivery.
Children between ___ who have elevated anticockroach
and antimouse IgE are at increased risk of wheezing, AR, and atopic dermatitis.
2-3 yrs old
The occurrence of 3 or more episodes of rhinorrhea
in the first year of life is associated with AR at
age 7 yr
The occurrence of _____ of rhinorrhea
in the first year of life is associated with AR at age 7 yr
3 or more episodes
Intriguingly, the exposure to __ early in childhood protects against the development of atopy
dogs, cats, and endotoxin
is beneficial, but it does not need to be exclusive
Prolonged breastfeeding
There is also a decreased risk of
asthma, AR, and atopic sensitization with
early introduction to wheat,
rye, oats, barley, fish and eggs.
Two factors necessary for expression of AR a
sensitivity to an allergen
and the presence of the allergen in the environment
AR classification
seasonal and perennial
perennial is giving way to the designations
intermittent
and persistent.
The 3 sets of terms are based on different suppositions, but oral allergens are not the main cause of all forms of AR irrespective of terminology
false
3 sets
inahalant allergens
main cause
AR may also be categorized as
mild-intermittent, moderate-severe intermittent, mild-persistent, and moderate severe persistent
The symptoms of intermittent AR occur
on
<4 days per week or for <4 consecutive weeks
In persistent AR
symptoms occur on
> 4 days per week and/or for >4 consecutive weeks.
The symptoms are considered severe when they are not troublesome, the sleep is normal, there is impairment in daily activities, and incapacity at work or school
false
mild
no impairment
no incapacity
Severe symptoms result
sleep disturbance, and impairment in daily activities and school
In temperate climates, airborne pollen responsible for exacerbation of intermittent AR appear in distinct phases:
trees pollinate in the spring,
grasses in the early summer,
and weeds in the late summer
In warm climates, mold spores persist outdoors only in the summer, but in cold climates throughout the year.
In temperate climates, mold spores persist outdoors only in the summer, but in warm climates throughout the year.
Symptoms of intermittent AR typically cease with the appearance of fire
Symptoms of intermittent
AR typically cease with the appearance of frost.
Knowledge of the time of occurrence of symptoms, of the regional patterns of pollination and mold sporulation, and of the patient’s specific IgE is necessary for the recognition of the cause of intermittent AR
true
Persistent AR is most often
associated with the indoor allergens:
house dust mites, animal danders, mice, and cockroaches
mice allergies are of major importance
in the United States.
Cat and dog allergies are of major importance
in the United States.
The allergens from ______
may remain airborne for a prolonged time.
saliva and sebaceous secretions
The ubiquitous major cat allergen,
fel d 1
may be carried on cat owners’ clothing into such “catfree” settings as schools and hospitals.
fel d 1
mild symptoms
- Normal sleep
- Normal daily activities
- Normal work and school
- No troublesome symptoms
Moderate-to-severe
One or more items
* Abnormal sleep
* Impairment of daily activities,
sport and leisure
* Difficulties caused at school
or work
* Troublesome symptoms
The exposure of an atopic host to an allergen leads to specific
IgE production.
The clinical reactions on reexposure to the allergen have been designated as
early-phase and late-phase allergic responses.
Bridging of the IgE molecules on the surface of mast cells by allergen initiates
early-phase allergic response,
characterized by degranulation
of mast cells and release of preformed and newly generated inflammatory
mediators
early-phase allergic response,
early-phase allergic response, characterized by degranulation of mast cells and release of preformed and newly generated inflammatory
mediators including
histamine
prostaglandin 2
cysteinyl leukotrienes
Late-phase allergic response appears ___ following
allergen exposure.
4-8 hr
Inflammatory cells, including ____ infiltrate the nasal
mucosa.
basophils
eosinophils,
neutrophils
mast cells
mononuclear cells,
Eosinophils release proinflammatory mediators, including
cysteinyl leukotrienes
cationic proteins
eosinophil peroxidase
major basic protein
serve as a source of interleukin (IL)-3, IL-5,
granulocyte-macrophage colony-stimulating factor, and IL-13.
major basic protein
Repeated intranasal introduction of allergens causes —___a more brisk response even with a lesser provocation.
“priming”
Over the course of an allergy season a multifold increase in ______ takes place.
submucosal mast cells
once thought to have a role exclusively in the earlyphase allergic response, have an important function in sustaining chronic allergic disease.
submucosal mast cells
Allergens, autoantigens, and components of
superimposed infectious agents ________
activate the immune system.
Older children snort, but younger children
tend to blow their noses.
Older children blow their noses, but younger children
tend to sniff and snort.
Nasal itching brings on grimacing, twitching,
and picking of the nose that may result in
epistaxis
Children with AR often perform the
allergic salute
an upward rubbing of the nose with
an open palm or extended index finger
allergic salute
This maneuver relieves itching
and briefly unblocks the nasal airway.
allergic salute
gives rise to the nasal
crease, a horizontal skin fold over the bridge of the nose
allergic salute
The diagnosis
of AR is based on symptoms
in the absence of an upper respiratory
tract infection and structural abnormalities
Typical complaints of AR include
intermittent nasal congestion
itching
sneezing
clear rhinorrhea
conjunctival irritation
Symptoms decrease with greater exposure to the
responsible allergen.
increase
The patients may not lose their sense of smell and
taste.
The patients may lose their sense of smell and
taste.
Some patients experience
headaches, wheezing, and coughing
is often more severe at night, causing mouth breathing and snoring, interfering with sleep, and arousing irritability
Nasal congestion
Signs on physical exam include
abnormalities of facial development,
dental malocclusion
“allergic gape”
chapped lips,
“allergic shiners
transverse nasal crease
continuous openmouth
breathing,
“allergic gape”
(dark circles under
the eyes)
“allergic shiners”
Conjunctival edema, itching,
tearing, and hyperemia are not frequent findings.
Conjunctival edema, itching,
tearing, and hyperemia are frequent findings.
A nasal exam performed
with a source of light and a speculum may reveal clear nasal secretions;
edematous, boggy, and bluish mucus membranes with little or no erythema; and swollen turbinates that may block the nasal airway
It may be necessary to use a____ to perform an adequate examination.
topical decongestant
Thick, purulent nasal secretions indicate the presence of infection.
true
Evaluation of AR calls for a thorough history, including details of the patient’s environment and diet and family history of allergic conditions such as _____ physical examination, and laboratory
evaluation
eczema, asthma, and AR,
Symptoms that include
sneezing, rhinorrhea, nasal
itching, and congestion
laboratory findings of ___results typify AR
elevated IgE,
specific IgE antibodies, and positive allergy skin test
Intermittent AR differs from persistent AR by
history and skin test results
causes sporadic symptoms
Nonallergic rhinitides
Nonallergic rhinitides causes
often unknown
imitates AR in presentation and response to treatment, but without elevated IgE antibodies.
Nonallergic inflammatory rhinitis with eosinophils
characterized by
excessive responsiveness of the nasal mucosa to physical stimuli
Vasomotor rhinitis
nonallergic conditions ____ mimic AR
infectious rhinitis
structural problems
rhinitis medicamentosa
hormonal rhinitis associated with pregnancy or hypothyroidism
neoplasms
vasculitides;
granulomatous disorders
(caused by the overuse of topical vasoconstrictors);
rhinitis medicamentosa
structural problems
nasal polyps and septal deviation;
Occupational risks for rhinitis
allergens and irritants
allergens
grain, dust, insects, latex, enzymes
irritants
wood dust, paint, solvents,
smoke, cold air
frequently associated with complications and comorbid conditions.
allergic rhinitis
characterized by itching, redness and swelling
of the conjunctivae
Allergic conjunctivitis
Allergic conjunctivitis has been reported in at least ___ of the population
20%
Allergic conjunctivitis has been reported in more the ___of patients with AR, most frequently in older
children and young adults
70%
common complication of AR, sometimes associated
with purulent infection, but most patients have negative bacterial
cultures despite marked mucosal thickening, and sinus opacification.
Chronic sinusitis
The inflammatory process is characterized by marked
eosinophilia
Allergens, possibly ____, are the inciting agents.
fungal
The sinusitis of triad asthma
asthma
sinusitis with nasal polyposis
aspirin sensitivity
often responds poorly to therapy
asthma
coexists with asthma may be taken too lightly or completely overlooked.
rhinitis
Up to ___ of patients with asthma have AR
78%
__ of patients with AR have asthma.
38%
Aggravation of AR coincides
with
exacerbation of asthma,
treatment of nasal inflammation
reduces
bronchospasm, asthma-related emergency department visits, and hospitalizations.
Postnasal drip
associated with AR commonly
causes persistent or recurrent cough
Eustachian tube obstruction and
middle ear effusion are frequent complications
true
Chronic allergic
inflammation causes hypertrophy of adenoids and tonsils that may be
associated with
eustachian tube obstruction, serous effusion, otitis
media, and obstructive sleep apnea
AR is linked to ____ in children
snoring
There is association between rhinitis and sleep abnormalities and subsequent daytime fatigue
true
The Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ) is suitable for children
6-12 yr old
Adolescent Rhinoconjunctivitis
Quality of Life Questionnaire (ARQLQ) is appropriate
for patients
12-17 yr of age
Children with rhinitis do not have anxiety and
physical, social, and emotional issues that affect learning and the ability to integrate with peers.
false- have
AR disorder contributes to
headaches and fatigue, limits daily activities, and interferes with sleep
There is evidence
of impaired cognitive functioning and learning that may be exacerbated by the adverse effects of
sedating medications.
an important cause of lost school attendance, resulting in more than 2 million days of absence in the United States annually
rhinitis
Rhinitis is an important cause of lost school attendance, resulting in more than____of absence in the United States annually.
2 million days
provide the best method for detection of
allergen-specific IgE
Epicutaneous skin tests
positive predictive value of ___ for the epidemiologic
diagnosis of AR
48.7%
inexpensive and sensitive, and the
risks and discomfort are minimal
Epicutaneous skin tests
Responses to seasonal respiratory
allergens are rare before ____ of exposure
2 seasons
Responses to seasonal respiratory
allergens in children ___- seldom display positive skin test responses to these allergens
<1 yr
To avoid
false-negative results, montelukast should be withheld for
1 day
To avoid
false-negative results most
sedating antihistamine preparations should be with held for
3-4 days
To avoid
false-negative results nonsedating
antihistamines should be with held for
5-7 days
Serum immunoassays for____ to
allergens provide a suitable alternative
specific IgE
serum immunoassays positive predictive value
43.5%
Serum immunoassays for specific IgE to
allergens provide a suitable alternative for
patients with dermatographism or extensive dermatitis, those taking medications that interfere with mast cell degranulation, others at high risk for anaphylaxis, and some who cannot cooperate with the
procedure.
Presence of___in nasal smear supports the diagnosis
of AR,
eosinophils
Presence of _____ in nasal smear supports the diagnosis of infectious rhinitis
neutrophils
Eosinophilia and
measurements of total serum IgE concentrations have relatively
low sensitivity.
current goals of treatment.
Safe and effective prevention and/or relief of symptoms
Specific measures to limit indoor allergen exposure
may reduce the risk of sensitization and symptoms of allergic respiratory disease.
Sealing the patient’s mattress, pillow, and covers in
allergen-proof encasings
Bed linen and blankets should be washed every week in hot water
Sealing the patient’s mattress, pillow, and covers in
allergen-proof encasings
reduces the exposure to mite allergen.
Bed linen and blankets should be washed every week in hot water . what is the temperature
(>54.4°C
[130°F]).
The only effective measure for avoiding animal allergens in the home is the
removal of the pet.
Avoidance of pollen and outdoor
molds can be accomplished by
staying in a controlled environment.
allows for keeping windows and doors closed, reducing
the pollen exposure.
Air conditioning
lower the counts of airborne mold spores
High-efficiency particulate air filters
help reduce sneezing, rhinorrhea and ocular
symptoms.
Oral antihistamines
Administered as needed they provide acceptable treatment for mild-intermittent disease
Oral antihistamines
Antihistamines have been classified as
first generation
relatively sedating)
ntihistamines have been classified as
second generation
relatively nonsedating)
Antihistamines usually are administered by
mouth
Antihistamines are also available for
topical ophthalmic and intranasal use
are preferred because they cause less sedation
Second-generation antihistamines
Preparations containing _____, typically in combination with other agents, are used for relief of nasal and sinus congestion and pressure and other symptoms such as rhinorrhea, sneezing, lacrimation, itching eyes, oronasopharyngeal itching, and cough.
pseudoephedrine
is available without prescription
Pseudoephedrine
Pseudoephedrine is generally in fixed combination with other agents such as first-generation antihistamines:
brompheniramine, chlorpheniramine,
triprolidine
Pseudoephedrine is generally in fixed combination with other agents such as 2nd-generation antihistamines:
desloratadine, fexofenadine,
loratadine; antipyretics: acetaminophen, ibuprofen
Pseudoephedrine is generally in fixed combination with other agents such as antitusssive:
guaifenesin, dextromethorphan;
anticholinergic
methscopolamine
Pseudoephedrine is an oral vasoconstrictor disfavored for causing ____
irritability
and insomnia and for its association with infant mortality.
younger children ___ are at increased risk
2-3 yr of age
younger children (2-3 yr of age) are at increased risk of overdosage and toxicity, some manufacturers of oral nonprescription cough and cold preparations have voluntarily revised their product labeling to warn against the use of preparations containing pseudoephedrine for children younger than
4 yrs old
Pseudoephedrine is misused as a starting
material for the synthesis of
methamphetamine and methcathinone
The anticholinergic nasal spray ____is effective for
the treatment of serous rhinorrhea
ipratropium bromide
Intranasal decongestants ____ should be used for less
than 5 days
oxymetazoline and phenylephrine
Intranasal decongestants
(oxymetazoline and phenylephrine) should be used for
less than 5 days
Intranasal decongestants should not to be repeated ____ in order to avoid rebound nasal congestion
more than once a month
(available as nonprescription drug) is effective but requires frequent administration, q4h.
Sodium cromoglycate
have a modest effect on rhinorrhea
and nasal blockage
Leukotriene-modifying agents
is a good adjunctive option
with all other treatments of AR.
Nasal saline irrigation
Patients with more persistent, severe
symptoms require____-s, the most effective therapy for AR,
intranasal corticosteroid
a treatment that may be beneficial also for concomitant allergic conjunctivitis
intranasal corticosteroid
are absorbed from the gastrointestinal
tract, as well as from the respiratory tract
Beclomethasone, triamcinolone,
and flunisolide
offer greater topical activity with lower
systemic exposure.
budesonide, fluticasone,
mometasone, and ciclesonide
More severely affected patients may benefit from
simultaneous treatment with
oral antihistamines and intranasal corticosteroids.
is an effective treatment for AR and allergic
conjunctivitis.
Allergy immunotherapy
Immunotherapy administered by ____ should be considered for children in whom IgE-mediated allergic symptoms cannot be adequately controlled by avoidance and medication, especially
in the presence of comorbid conditions
subcutaneous injection
has been used successfully in Europe and South America
Sublingual immunotherapy
considered investigational in the United
States, and there are no extracts for sublingual administration licensed
by the FDA
Sublingual immunotherapy
given subcutaneously has a dose-dependent effect on seasonal AR; its role compared with standard therapy has yet to be determined.
Omalizumab
(anti-IgE antibody)
Omalizumab
Typically, treatment of AR with oral antihistamines and inhaled corticosteroids provides sufficient relief for most cases of coexisting allergic conjunctivitis.
true
are of some value for the treatment of ocular symptoms, but ophthalmic corticosteroids remain the most potent pharmacologic agents for ocular allergy.
Intranasal
corticosteroids
They carry the risk of adverse effects, such as
delayed wound healing
secondary infection
elevated intraocular pressure
formation of cataracts.
The reported rates of remission
among children are between
10% and 23%.
Structural/mechanical factors:
- Deviated septum/septal wall anomalies
- Hypertrophic turbinates
- Adenoidal hypertrophy
- Foreign bodies
Nasal tumors:
- Benign
- Malignant
- Choanal atresia
Infectious:
- Acute
- Chronic
Inflammatory/immunologic:
- Granulomatosis with polyangiitis
- Sarcoidosis
- Midline granuloma
- Systemic lupus erythematosus
- Sjögren syndrome
- Nasal polyposis
Physiologic:
- Ciliary dyskinesia syndrome
- Atrophic rhinitis
Hormonally induced
- Hypothyroidism
- Pregnancy
- Oral contraceptives
- Menstrual cycle
- Exercise
- Atrophic
Drug induced:
Rhinitis medicamentosa
* Oral contraceptives
* Antihypertensive therapy
* Aspirin
* Nonsteroidal antiinflammatory drugs
Reflex induced:
- Gustatory rhinitis
- Chemical or irritant induced
- Posture reflexes
- Nasal cycle
- Environmental factors:
- Odors
- Temperature
- Weather/barometric pressure
- Occupational
- Nonallergic rhinitis with eosinophilia syndrome
- Perennial nonallergic rhinitis (vasomotor rhinitis)
- Emotional factors
Rhinitis > non-allergic> Infective >
Acute rhinosinusitis, Chronic rhinosinusitis
Rhinitis > non-allergic> Infective >Chronic rhinosinusitis Exclude predisposing causes
- Cystic fibrosis
- Primary ciliary dyskinesia
- Immunodeficiency
- Immunopathology
- Polyps
Rhinitis > non-allergic>non -Infective >Non-allergic rhinitis
with eosinophilia
Consider aspirin,
entopy (local nasal IgE)
Rhinitis > non-allergic>non -Infective > Immunopathologic
findings
- Churg-Strauss syndrome
- Wegener granulomatosis
- Sarcoidosis
- Relapsing polychondritis
- Systematic lupus
erythematosus
Rhinitis > non-allergic>non -Infective >Structural abnormalities
- Deviated septum
- Nasal valve dysfunction
- Nasal polyps
- Foreign body
- Adenoidal hypertrophy
- Choanal atresia
- Cerebral fluid leak
- Nasal or CNS tumors
Rhinitis > non-allergic>non -Infective >Hormonal
- Pregnancy
- Menstrual cycle
- Puberty
- Hormone
replacement
therapy - Acromegaly
- Hypothyroidism
Rhinitis > non-allergic>non -Infective >drug induced
- Oral contraceptive
- Rhinitis medicamentosa
- Antihypertensives
- Cocaine abuse
- Aspirin or NSAID
Rhinitis > non-allergic>non -Infective >others
- Non-infective,
non-allergic rhinitis
Neurogenic (gustatory,
emotional, cold-air
induced) - Atrophic
- Gastro-esophageal
reflux - Idiopathic
Desloratadine
Clarinex Reditabs strength
2.5 mg, 5 mg
Desloratadine
Clarinex Reditabs formulation
Orally disintegrating tablet
Desloratadine
Clarinex Reditabs dosing
Children 6-11 mo of age: 1 mg once daily
LEUKOTRIENE ANTAGONIST
Montelukast
Singulair
10 mg Tablets 6 mo-5 yr: 4 mg daily
Desloratadine
Clarinex Tablets
5 mg Tabs Children 12 mo-5 yr of age: 1.25 mg once daily
Clarinex Syrup
0.5 mg/mL Syrup Children 6-11 yr of age: 2.5 mg once daily
Adults and adolescents ≥12 yr of age: 5 mg once daily
Levocetirizine dihydrochloride
Xyzal Oral Solution
0.5 mg/mL Solution 6 mo-5 yr: max 1.25 mg once daily in the P.M.
6-11 yr: max 2.5 mg once daily in the P.M.
Singulair Chewables*
4 mg, 5 mg Chewable tablets 6-14 yr: 5 mg daily
