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m4 ENT > Allergic Rhinitis > Flashcards

Allergic Rhinitis Flashcards

1
Q

Definition of Allergic Rhinitis

A
  • lgE mediated (type I hypersensitivity reaction) inflammation of nasal mucosa after allergen mucosa
  • A/w personal and family history of atopy (eczema/atopic dermatitis, asthma, allergic conjunctivitis)
  • Bilateral involvement
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2
Q

Pathogenesis of allergic rhinitis

A

Starts with allergen exposure and sensitisation
lgE mediated (type I hypersensitivity reaction)

  1. Early phase: mast cells and basophils degranulate -> releasing histamine -> vasodilation and mucus production:
    - rhinorrhea
    - nasal congestion
    - nasal itching
    - sneezing
  2. Late phase: cellular (eosinophils, lymphocytes, monocytes) infiltration -> remodelling
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3
Q

Triggers of allergic rhinitis

A

Aeroallergens:
Any airborne substance that can result in an IgE-mediated allergic response
- perennial allergens (experience symptoms year-round): dust mites*, cat and dog dander and cockroach
- tree, grass, and weed pollen

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4
Q

Clinical features of allergic rhinitis

A

2/4 cardinal symptoms:
- Rhinorrhea
- Nasal congestion
- Nasal itching
- Sneezing
* reversible spontaneously or with treatment

+/- Ocular symptoms:
- itchy eyes
- red eyes
- tearing

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5
Q

Signs in allergic rhinitis

A

*bilateral involvement

  1. Allergic salute
    - characteristic & habitual gesture of wiping/rubbing the nose in an upwards or transverse manner with the fingers, palm, or back of the hand
  2. Supratip crease
  3. Allergic shiners
    - infraorbital edema and darkening due to venous congestion secondary to impeded blood flow through edematous nasal mucosa
  4. Dennie-Morgan fold/line
    - fold or line in the skin below the lower eyelid
  5. Geographic tongue
    - inflammatory but harmless condition affecting the surface of the tongue
    - Patches on the surface of the tongue are missing papillae
    - Patches are smooth and red, often with slightly raised borders
  6. Cobblestone pharynx
    - inflamed tissue in the back of your throat that looks bumpy
  7. Pale and edematous nasal mucosa and inferior turbinate
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6
Q

Complications of allergic rhinitis

A

Sinusitis
Anosmia
Nasal polyps

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7
Q

Classification of allergic rhinitis

A
  • Duration: intermittent or persistent
  • Severity of symptoms and QOL: Mild or moderate

Intermittent
< 4 days/week OR < 4 weeks
Persistent
> 4 days/week AND > 4 weeks

Mild
- Normal sleep
- Normal daily activities, sport and leisure
- Normal work and school
- No troublesome symptoms

Moderate-Severe (≥1 item(s))
- Abnormal sleep
- Impaired daily activities, sport or leisure
- Problems at work or school
- Troublesome symptoms

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8
Q

Diagnosis of allergic rhinitis involves

A
  1. Hallmark symptoms, history suggesting atopy
  2. PE findings
  3. Allergy testing
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9
Q

Investigations for allergic rhinitis

A

Allergy testing is unnecessary in patients with clear history of symptoms triggered by specific allergens

  1. Skin prick test (in vivo)**
  2. Serum specific IgE test (in vitro)**
  3. Intradermal testing (in vivo)
  4. End-organ provocation testing (in vivo)
  5. Patch test (in vivo)
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10
Q

How does skin prick test work?

A

Make markings using pen, apply allergens (suspended in normal saline), prick skin for allergens to enter
+ve control: Histamine
-ve control: Normal saline

+ve result: Wheal ≥ 3mm compared to -ve control

*Faster (15 min) and cheaper
*Indirect measure of cutaneous mast cell reactivity due to presence of specific lgE

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11
Q

Absolute C/I to skin prick testing

A
  • On beta-blockers (Adrenaline not able to work on beta receptors to cause bronchodilation during anaphylaxis)
  • Recent anaphylaxis
  • Allergy to peanut (May cause anaphylaxis)
  • Extensive skin disease (E.g. eczema known to ↓ skin reactivity to histamine)
  • Taken anti-histamines in past 3-5 days (yield false +ve results)
  • Pregnant
  • Dermatographism
  • Asthma (Poor control)
  • No clear skin
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12
Q

Relative C/I to skin prick testing

A

Too old or too young (too early for kids <5yo as immune system still developing)

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13
Q

Serum-specific IgE antibody test

A
  • Detects amount of IgE that reacts specifically with allergen
  • Gold standard, highly specific, quantitative and reflects severity of allergy
  • eg. Radioallergosorbent test (RAST)
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14
Q

Management of allergic rhinitis

A
  1. Patient education
    - increase patient compliance
  2. Allergen identification and avoidance
    - environmental control
  3. Pharmacotherapy
  4. Immunotherapy
  5. Surgical
    - Radiofrequency ablation of inferior turbinates (LA)
    - Inferior turbinate reduction (GA)
    - Septoplasty (GA)
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15
Q

Pharmacotherapy for allergic rhinitis

A
  1. Oral anti-histamines
  2. Topical nasal decongestants
    - Limit use to at most 5-7 days to prevent rhinitis medicamentosa
  3. Nasal irrigation (To improve mucociliary clearance)
  4. Intranasal steroid spray
    - Fluticasone / Mometasone
    - improvement seen 2 weeks later
    - maintenance therapy
  5. Cromolyn sodium (Mast cell stabiliser)
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16
Q

Immunotherapy for allergic rhinitis

A
  • Gradual exposure of patient to doses of allergen extract
  • In the long term (3 years), this induces changes in the immune system which modifies its response to the specific allergen
  • Subcutaneous injections or sublingual table/spray

Indications:
- Failed Conservative
- Failed Medical
- Severe Allergies

Side Effects:
- Rashes
- Chest Tightness
- Throat Tightness
- Eyelid swellings

17
Q

How is food allergy a/w allergic rhinitis?

A
  • Peanut, milk, egg allergies predispose to development of allergic rhinitis and asthma
  • Patients with multiple food allergies are also at increased risk of developing AR and asthma
  • AR more frequently associated with a secondary rather than a primary food disorder
    -> secondary mild food allergy aka oral allergy syndrome
18
Q

Food allergic reaction

A

Immediate (IgE mediated) v.s. delayed (non-IgE mediated)

19
Q

Presentations of food allergy

A

AR
Rhinosinusitis
Recurrent URTI
Chronic postnasal drip
Disturbing phlegm in throat
Chronic cough
Headache/ Facial pain/ Migraine
Eczema
Asthma
IBS

20
Q

Types of Hypersensitivity reactions (Gell and Coomb’s classification)

A

I: Immediate (IgE)
II: Cytotoxic (IgG or IgM + Complement)
III: Immune complex reaction (IgG or IgM complement)
IV: Cell mediated, delayed hypersensitivity (Sensitized Lymphocytes)

21
Q

Clinical features of IgE-mediated food allergy -> histamine release

A
  • <5% of food allergic reactions
    Immediate, acute onset of symptoms

Urticaria
Angioedema
Abdominal cramps, diarrhoea
Asthma
Anaphylactic shock, death

22
Q

Clinical features of non-IgE mediated/delayed food allergy

A
  • > 95% of food allergic reactions
    Delayed reaction (hours to days)
  • Type 3 hypersensitivity
  • Exposure dependant
  • Masking phenomenon present → symptoms improve or disappear with ingestion of same food
  • Affects multiple organ systems
  • Associated with eczema
23
Q

How to diagnose non-IgE, delayed food allergic?

A

Diet elimination
Oral challenge food test
Intradermal progressive dilution food test

24
Q

Management of food allergy

A

IPDFT/ Elimination diet
Avoidance
Rotation diet
Food neutralizing injections/ Sublingual drops
Pharmacotherapy

25
Q

Why is allergic rhinitis alternating in nature?

A

Due to nasal cycle - physiological phenomena:
- When vasodilation occurs in 1 part of nose, other part
vasoconstricts
- Blood supply alternates between both parts of nose every 30 minutes to 3 hours
- Nasal obstruction occurs on side with vasodilation and more blood supply aka decongested side swaps

26
Q

What is an allergic march/atopy?

A

In order of progression
1. Food allergy
2. Atopic dermatitis
3. Asthma
4. Allergic rhinitis

Having one type of atopic disease makes one more likely to develop another

27
Q

Allergen avoidance to house dust mites

A
  • Wash all bedding every 1-2 weeks at 60 degrees to kill house dust mites
  • Remove thick fabric items from the environment
  • Dust mite barrier sheets
28
Q

IgE mediated vs non-IgE mediated allergies

A

IgE mediated
- quick onset
- eg. anaphylaxis
- clear mechanism
- easy to diagnose
- validated tests

Non-IgE mediated
- delayed onset
- eg. GIT symptoms, eczema
- unclear mechanism
- hard to diagnose
- less validated tests

29
Q

Food intolerance

A
  • ie. lactose intolerant
  • non-immune mediated
  • milder symptoms
  • mainly GI symptoms
  • would not lead to anaphylaxis
  • dependent on amount eaten
30
Q

What is oral allergy syndrome?

A

Cross reactivity in patients with inhalant allergies who develop allergies to associated food groups
- for eg. allergens are found in both pollen and kiwi fruit
- late onset in older children and adult
- symptoms confined to oral cavity/throat
- immunotherapy

31
Q

What are the species of house dust mites allergen in Singapore and which is most common trigger?

A
  1. Dermatophagoides pteronyssinus (MOST COMMON)
  2. Dermatophagoides farinae,
  3. Blomia tropicalis

m4 ENT (25 decks)

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