Allergic Rhinitis e-Module Flashcards
Rhinitis definition
inflammation of nasal mucosa
how much of the population does rhinitis affect
40%
Rhinitis is the presence of one or more of what symptoms
sneezing
rhinorrhea
nasal congestion
nasal itching
what is the most common form of chronic rhinitis
allergic rhinitis AKA hay fever
25% of CAN pop
+prevalence is increasing
What is AR
systemic
IgE antibody-mediated
inflammatory disease
what characterizes AR
inflammation (swelling and or irritation of inside of nose (nasal mucosa) following allergen inhalation
classifications of allergens
indoor and outdoor
outdoor allergens
grass or tree pollen
mould
indoor allergens
dust mites and insects
animal dander
impacts of AR
negative impacts on social life, sleep, concentration ability, school performane, wrk productivity
where is prevalence hgihest
school aged children
-may be more common in children with history of asthma and atopic dermatitis
atopic triad
AR, asthma, atopic dermatitis
How get AR
genetic predisoposition
- 1 parent affected, children 30% chance dev
- 2 parents –> 50%
AR localization
historically
-nose and nasal passages
Current evidence
-component of systemic airway disease involving entire respiratory tract
allergy/sinus relief is in top 10 OTC cat in CAN (T/F)
True
How RPh optimize care for AR patients
need to ID patient cohorts who self-select and are at high risk of mismanagement
—> opportunity for RPh to enegage pateints and encourage discussion abt AR mngmnt
Pathophysiology and Etiology
multifactorial disease induced by gene-environment interactions
characteristic symptoms are result of an antigen-antibody mediated reaction
-3 phases
what are the 3 phases of the antigen-antibody mediated reaction
sensitization
immediate response
late phase reaction
Sensitization
- allergen enters nose –> sensitizes mucosal mast cells
- sensitization occurs via t-cell release of cytokines
- cytokines promote allergen-specificIgE antibody production by plasma cells
- IgE binds to mast cells and basophils
THIS FIRST PHASE OCCURS ON 1ST CONTACT WITH ALLERGEN
-second and third phase are on re-exposure to allergen in sensitized individual
Immediate response
early phase reaction occurs within minutes of exposure
-lasts 30-90 minutes
allergen bound to allergen specific IgE and the sensitized mast cells release preformed mediators
+histamine
+prostaglandin D2
+kinins
inflammatory mediators
-attract, recruit and activate additional inflammatory mediators into nasal mucosa —> late-phase response
+eosinophils, neutrophils and T lymphocytes
Late reaction
associated with chronic inflammation charcterized by migration of inflammatory cells
+eosinophils, monocytes, macrophages, basophils
begin 4-8 hours after allergen exposure and peak 12-24 hours
release of cytokines chemokines and growth factors
-further perpetuate inflammatory response
results in recurrent symptoms that often persist
-usually nasal congestion
Signs and symptonms
Nasal obsturction (congestion) sneezing nasal itching rhinorrhea Postnasal drainage (postnasal drip) irritability fatigue
Common symptoms patients rarely report directly
subset of patients: concomitant allergic conjunctivitis \+bilateral ocular itching \+redness \+tearing \+burning
Other symptoms
- facial P (over cheeks and forehead
- itchy throat/palate
- ear fullness and popping
Clinical presentation of AR depending on phase of allergic reaction
Sensitization phase
- asymptomatic
Early response (cts to late response)
- sneezing,
- rhinorrhea,
- nasal and palatal pruritis,
- congestion
Late Response
- nasal congestion is particularly common
- fatigue
- malaise
- irritability
- neurocognitive deficits (possible)
- allergic shiners
- morgan’s lines
- transverse nasal creases
Physical exam: Face
Allergic facies -highly arched palate -open mouth (chronic mouth breathing) -dental malocclusion TYPICALLY SEEN IN CHILDREN WITH EARLY ONSET AR
OTHER:
- frequent gimacing
- twitching face and nose (itchy mucus membs)
younger children typically dont blow nose
- frequently rub, snort, sniff, cough, clear throats
- scratch their itchy palates with their tongues, producing a clicking sound
Physical signs: eyes
Dennie-morgan lines
-accentuated lines or folds below lower eyelids that may become more noticeable with age —> suggest concomitant allergic conjunctivitis
Allergic conjunctivitis
-ocular itching, burning, tearing, conjunctival injection (redness faiding twd edges)
Allergiv shiners
- infraorbital edema and darkening due to subcutaneous venodilation
- more severe disease more pronounced discoloration under eyes
Physical exam: nose
allergic salute -transverse nasal crease casued byrepeated rubbing and pushing/wiping tip -upward motion -try and relieve itching and open airway \+more common in children
Nasal mucosal swelling, bleeding
bluish or pale, thin secretions
nasal polyps or other structural abnormalities visible by internal endoscopy
physical signs: posterior oropharynx
postnasal drip
- nasal passages obstructed, rhinorrhea may be visible dripping down posterior pharynx
- leads to cough/ frequent throat clearing
- constant swallowing or halitosis
lymphoid hyperplasia
-hyperplastic lymphoid tissue lining posterior pharynx (resembles cobblestones)
tonsillar hypertrophy
-persistently enlarged tonsils
physical exam: ears
-generally normal
- tympanic membranes may retract
- serous fluid may accumulate behind TMs of patients with seig nasal mucosal swelling
- eustacian tube dysfunction
pneumatic otoscopy –> asses eustachian tube dysfunction
valsalva’s maneuver –> asses for fluid behind ear drum
physical exam:sinuses
palpitation of sinuses for sensitivity
maxillary tooth sensitivity
physical exam: chest and skin
Wheezing (sign of concurrent asthma
atopic disease
what is one of most important sequalae of untreated AR
sleep disturbed breathing
Cognitive and psychiatric issues: children/adolescents
- ADHD
- lower exam scores during peak pollen seasons
- poor conc
- impaired athletic performance
- low self esteem
Cognitive and psychiatric issues: in adults
- anxiety
- depression
- reduced academic performane
- reduced work productivity (lower than that of patients with asthma)
- impaired sexual performance
- lower quality of life scores
Classification: traditional
perennial (throughout year)
seasonal (specific season)
FALLEN OUT OF FACOUR
-seasonal allergies may exp symptoms year-round and perennial may experioence symptoms intermittently
modern classification of AR
based on symptom duration AND severity
- intermittent or persistent
- mild, moderate, severe
Intermittent AR
<4 days/wk OR <4 consecutive weeks
persistent AR
> 4days/wk AND >4 consecutive weeks
mild symptoms
normal sleep
symptoms not bothersome
no impairment of daily activities, sports, leisure
normal work/school
moderate/severe
abnormal sleep OR
symptoms are bothersome OR
impairment of daily activities, sports, leisure OR
problems at work/school
how subjectively quantify patient symp severity
VAS - visual analogue scale
For AR, usually asked over past 24 hours how troublesome are allergy symptoms (0-10)
10cm horizontal line
-not bothersome ———————–very bothersome
VAS score less than 2
well-controlled AR
VAS score [2,5)
partly controlled disease
VAS score 5 or more
uncontrolled AR
MASK-air
reliable valid highly engaging tool
treatment scroll list
VAS to assess AR control and school/work productivity
MASK-air VAS questions
VAS 1 (overall symptoms): “Overall, how much are your allergic symptoms bothering you today?”
VAS 2 (Rhinitis): “How much are your nose symptoms bothering you today?”
VAS 3 (Conjunctivitis): “How much are your eye symptoms bothering you today?”
VAS 4 (asthma): “How much are your asthma symptoms bothering you today?”Protective and risk factors
falmily history = one of strongist predictors of dev of AR
Others:
- male gender
- birth during pollen season
- firstborn status
- overweight
- maternal exposure to indoor allergens sa dust mite allergen
- serum IgE >100IU/mL before age 6
- presence of allergen-specific IgE
SCHOLAR
S: main & associated symptoms: nasal pruritus, congestion, rhinorrhea, sneezing, eye involvement
C: characteristics of allergic symptoms: frequency, severity: VAS score, QoL impact
H: history of AR
O: onset/timing/pattern/seasonality of symptoms (e.g., intermittent, persistent)
Note: It’s not uncommon for patients to attribute persistent nasal symptoms to a “constant cold” and so it remains imperative to document both the duration and frequency of these “colds”.10
L: location of symptoms (e.g., nose, eyes, palate)
A: aggravating factors (e.g., triggers, irritants)
R: remitting factors (including therapies tried, regimens followed, and subsequent responses)
