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BMS250 > Allergic Rhinitis (Week 5) > Flashcards

Allergic Rhinitis (Week 5) Flashcards

1
Q

What is allergic rhinitis?

A

Characterized by a heightened sensitivity to a foreign protein (allergen) leading to eosinophilic inflammation of the nasal mucosa and paranasal sinuses.

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2
Q

What role do IgE and mast cells play in allergic rhinitis?

A

IgE antibodies bind to mast cells, triggering their activation and the release of proinflammatory mediators like histamine.

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3
Q

List the common clinical features of allergic rhinitis.

A
  • nasal congestion
  • obstructed airflow
  • clear and watery nasal discharge (increased mucous production)
  • postnasal drip
  • itching of the nose/throat/eyes
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4
Q

What are the two phases of allergic rhinitis pathophysiology?

A
  • Early phase response
  • Late phase response
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5
Q

Describe the early phase response in allergic rhinitis.

A

Triggered by mast cell degranulation and release of mediators like histamine, causing symptoms such as sneezing and nasal congestion.

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6
Q

What occurs during the late phase response of allergic rhinitis?

A

Inflammatory cells infiltrate the area, releasing mediators that prolong symptoms like sneezing and nasal congestion.

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7
Q

What are the risk factors for allergic rhinitis?

A

Atopy, which includes:

  • asthma
  • atopic dermatitis/eczema
  • other allergies

Note: parental history of allergic rhinitis, asthma, and pollen allergies are also well-documented risk factors

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8
Q

What role does gut microbiota play in allergic rhinitis?

A

Gut microbiota composition impacts immune function and may contribute to the pathogenesis of allergic diseases.

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9
Q

What are the two classifications of allergic rhinitis?

A
  • Seasonal Allergic Rhinitis (due to pollination of certain plants to which the patient is allergic)
  • Perennial Allergic Rhinitis (all year round; however, intensity may vary)
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10
Q

What are some common allergens that trigger perennial allergic rhinitis?

A
  • Dust mites
  • Animal dander
  • Mold spores
  • Cockroaches
  • Food allergens
  • Infection

Note: Can also be aggravated by other irritants such as tobacco smoke, chemical fumes, and air pollution

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11
Q

What complications can arise from allergic rhinitis?

A
  • Adenoid hypertrophy (Grade 1 to 4)
  • Eustachian tube dysfunction (ear fullness, otalgia, ear-popping)
  • Chronic rhinosinusitis (nasal inflammation and congestion or discharge lasting longer than 3 months)
  • Nasal polyps (noncancerous growths)
  • obstruction of osteomeatal draining leading to higher risk of bacterial sinus infections
  • sleep disruption
  • learning disturbances in children (cognitive, fatigue, memory impairments)

Note: adenoids are masses of lymphatic tissue that help fight infections but can obstruct the nose if they get too enlarged

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12
Q

True or False: Nonallergic rhinitis includes symptoms like sneezing and itchy, watery eyes.

A

False

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13
Q

What is viral rhinitis characterized by?

A

Nasal drainage that is clear or white, nasal congestion, and sneezing, often accompanying other viral illness symptoms (e.g., headaches, malaise, body aches, coughing)

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14
Q

What is vasomotor rhinitis (VMR)?

A

A type of nonallergic rhinitis where symptoms occur in response to environmental conditions that do not typically affect normal individuals. May be related to a parasympathetic, sympathetic, and nociceptive nerve dysregulation, although etiology remains unclear

Note: also known as idiopathic rhinitis

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15
Q

What is rhinitis medicamentosa?

A

Nasal congestion caused by the overuse of topical nasal decongestants, also known as rebound congestion.

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16
Q

True or False: Allergic rhinitis (AR) is an inflammatory disease with complex pathophysiology, which suggests that it is caused by a complex interaction between more than 100 genetic loci and a complex environment

A

True

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17
Q

What symptoms are linked to allergic rhinitis in children?

A
  • Cognitive impairments
  • Fatigue
  • Memory issues
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18
Q

What is the role of the gut microbiome in allergic rhinitis?

A

Reduced diversity and dysbiosis of gut microbiota are associated with increased risk of allergic rhinitis.

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19
Q

What is the impact of environmental factors on the gut microbiome?

A

Diet, antibiotics, and habitat changes can lead to dysbiosis, affecting immune tolerance and increasing allergy risk.

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20
Q

List the main CLASSES of gut microbiota.

A
  • Bacteroidetes
  • Actinobacteria
  • Firmicutes
  • Proteobacteria

Note: These are not bacterial species themselves but phylums of bacteria present in the gut

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21
Q

What is the significance of nasal examination in allergic rhinitis?

A

It can reveal swelling of the nasal mucosa, clear secretions, and signs of comorbid conditions like asthma.

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22
Q

What is NARES?

A

NARES stands for Nonallergic Rhinitis with Eosinophilia Syndrome

it is characterized by nasal obstruction, congestion, sinusitis, polyposis, and nasal smears with marked eosinophilia (>25%) but no allergic response to inhalant allergens when tested topically or in vitro

The cause is still unknown

The cause of NARES remains unknown.

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23
Q

What is rhinitis medicamentosa?

A

Rhinitis medicamentosa is a condition of nasal congestion caused by the overuse of topical nasal decongestants (e.g., oxymetazoline, phenylephrine),

Also known as “rebound congestion”

Common agents include oxymetazoline and phenylephrine.

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24
Q

What changes during pregnancy contribute to nasal congestion?

A

Increased estrogen concentrations lead to increased hyaluronic acid in nasal tissue, resulting in nasal congestion and edema

A decrease in nasal cilia and an increase in mucous glands also contribute to nasal congestion, decreasing mucus clearance

During 2nd and 3rd trimesters, rhinitis is usually most severe

Note: Similar symptoms can appear premenstrually in some patients

Decreased nasal cilia and increased mucous glands also play a role.

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25
Q

What are the clinical features of chronic rhinosinusitis (CRS)?

A

Purulent drainage, facial/dental pain, nasal obstruction, hyposmia, headaches, ear pain, halitosis, fatigue

Fever is a less common indicator of severity.

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26
Q

How is chronic rhinosinusitis defined?

A

Inflammation of the nasal cavity and paranasal sinuses lasting more than 12 weeks.

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27
Q

What factors can contribute to chronic rhinosinusitis?

A
  • Biofilms
  • Bacterial superantigens
  • Osteitis
  • Allergy
  • Barrier and innate immune dysregulation
  • General host factors

These factors can lead to dysfunctional mucociliary clearance and bacterial overgrowth.

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28
Q

What is the role of superantigens in chronic rhinosinusitis?

A

Superantigens, produced by S. aureus, can activate the immune system, release cytokines, and promote inflammation.

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29
Q

What are nasal polyps?

A

Benign inflammatory and hyperplastic growths arising from the sinonasal mucosa

They can be single or multiple and are often associated with chronic rhinosinusitis.

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30
Q

What is the etiology of nasal polyps?

A

Majority due to T-helper 2 (Th2) cell-driven eosinophilia and IgE inflammation, often related to allergies.

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31
Q

What are the clinical features of nasal polyposis?

A

Progressive nasal obstruction, nasal and/or facial congestion, decreased sense of smell, rhinorrhea

Diagnosis can be made using anterior rhinoscopy or nasal endoscopy.

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32
Q

What is a deviated septum?

A

A wall composed of osteocartilaginous tissue that separates the two nasal cavities, which can cause nasal obstruction in some patients.

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33
Q

What are common clinical presentations of a deviated septum?

A
  • Headaches
  • Rhinosinusitis
  • High blood pressure
  • Obstructive sleep apnea
  • Breathing sounds

Headaches can occur due to contact between the septum and nasal mucosa.

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34
Q

What are the most common causes of acute pharyngotonsillitis?

A

Viral infections (70-85%) and bacterial infections, notably Group A beta-hemolytic streptococcus (GABHS)

Other pathogens include staphylococcus and nonhemolytic streptococci.

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35
Q

What are symptoms of acute pharyngotonsillitis?

A
  • Fever
  • Malaise
  • Odynophagia
  • Dysphagia
  • Foul breath

Airway obstruction may occur due to tonsillar enlargement.

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36
Q

What is the incubation period for EBV infection?

A

2 to 6 weeks.

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37
Q

What are the nonsuppurative complications of GABHS pharyngotonsillitis?

A
  • Scarlet fever
  • Acute rheumatic fever
  • Poststreptococcal glomerulonephritis
  • Pediatric autoimmune neuropsychiatric disorder associated with GABHS (PANDAS)

These complications can arise after an episode of pharyngotonsillitis.

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38
Q

What is a peritonsillar abscess?

A

A consequence of infection spreading from the tonsil into the space between the tonsillar capsule and pharyngeal muscle bed.

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39
Q

What are some common bacteria associated with peritonsillar abscesses?

A

GABHS, Staph aureus, Haemophilus influenza

GABHS stands for Group A beta-hemolytic streptococcus.

40
Q

What are the typical symptoms of peritonsillar abscesses?

A

Severe pain, odynophagia, muffled voice, dysphagia

Odynophagia refers to painful swallowing.

41
Q

What can inflammation of the pterygoid muscles lead to?

A

Trismus

42
Q

What examination findings are associated with peritonsillar abscesses?

A

Unilateral swelling of the palate, medial displacement of the tonsil, significant uvular deviation

Uvular deviation occurs towards the contralateral side.

43
Q

What is a parapharyngeal abscess?

A

An infection spreading through the superior constrictor muscle into the parapharyngeal space

44
Q

What are the consequences of untreated parapharyngeal abscesses?

A

Spread down the carotid sheath into the mediastinum

45
Q

What are common symptoms of retropharyngeal abscess?

A

Fever, dysphagia, muffled speech, noisy breathing, stiff neck, cervical lymphadenopathy

46
Q

Which bacteria are commonly involved in non-Group A streptococcal pharyngitis?

A

Group C and G streptococci

47
Q

What is a key characteristic of pharyngeal diphtheria?

A

Grayish, tightly adherent pseudomembrane covering the tonsils

48
Q

What are potential complications of diphtheria?

A

Airway compromise, cardiac toxicity, neurotoxicity

49
Q

Which sexually transmitted diseases can cause tonsillar infections?

A

Neisseria gonorrhoeae, Treponema pallidum

50
Q

What is oropharyngeal candidiasis commonly known as?

A

Thrush

51
Q

What are the symptoms of recurrent acute tonsillitis?

A

Recurrent episodes of acute tonsillitis with complete recovery between episodes

52
Q

What bacteria are frequently isolated in recurrent tonsillitis?

A

Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae

53
Q

What characterizes chronic tonsillitis?

A

Sore throat for at least three months, tonsillar inflammation, halitosis, persistent tender cervical adenopathy

54
Q

What are tonsilloliths?

A

Microbial biofilms that form within tonsillar crypts

55
Q

What is the appearance of minor aphthous ulcers?

A

Smaller than 1 cm, heals in 10-14 days

56
Q

What is a common trigger for aphthous ulcers?

A

Stress

57
Q

What is the most common pathogen causing supraglottitis?

A

Haemophilus influenzae type B (HIB)

58
Q

What are the clinical features of supraglottitis?

A

Fever, difficulty breathing, severe odynophagia, drooling, muffled voice, inspiratory stridor

59
Q

What is the primary cause of viral laryngitis?

A

Upper respiratory infections (URIs)

60
Q

Which bacteria are commonly involved in bacterial laryngitis?

A

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

61
Q

What are the symptoms of laryngitis?

A

Raspy voice, dry cough, anterior throat pain, need to clear throat

62
Q

What is bacterial tracheitis believed to result from?

A

Secondary bacterial colonization after a viral respiratory tract infection

63
Q

What is a characteristic finding in bacterial tracheitis?

A

Diffusely ulcerated tracheal mucosa and copious purulent secretions

64
Q

Differentiate between an allergy vs. rhinitis vs. allergic rhinitis

A

Allergy is characterized by a heightened sensitivity to a foreign protein - referred to as an allergen - elicited through various modes of exposure, including ingestion, contact, or inhalation.

Rhinitis is defined as an eosinophilic inflammation of the nasal mucosa and paranasal sinuses resulting from an IgE-mediated reaction.

Allergic Rhinitis manifests as nasal congestion, obstructed airflow, increased mucous production, and drainage. These manifestations arise due to an unfavourable response to environmental or ingested stimuli.

65
Q

Histamine, a pivotal mediator in allergic rhinitis, stimulates sensory nerve endings of the ____ cranial nerve –> elicits sneezing

A

5th cranial nerve (trigeminal nerve)

66
Q

Histamine, along with leukotrienes and prostaglandins, prompts ________ gland secretion (rhinorrhea) while affecting blood vessels to induce nasal congestion

A

mucus gland

67
Q

In the late phase response, 4-6 hours after antigen stimulation, there is prolongation of symptoms (sneezing, rhinorrhea, and sustained nasal congestion) lasting for about ______ hours

A

18-24 hours

68
Q

During late phase allergic rhinitis, release of cytokines and leukotrienes leads to the influx of what type of cells into the affected area via chemotaxis?

A
  • T lymphocytes
  • basophils
  • eosinophils

Note: These cells release a variety of mediators such as leukotrienes, kinins, and histamine, contributing to symptoms persistence and the progression of the late phase

69
Q

Mast cells and release of which cytokines are crucial to the late phase response?

A
  • IL-4
  • IL-5
  • IL-13

Note: These cytokines can upregulate the expression of adhesion molecules such as VCAM-1 on endothelial cells, facilitating the infiltration of eosinophils, T-cells, and basophils into the nasal mucosa

70
Q

Early Phase vs. Late Phase allergic rhinitis

A

Early Phase:
- antigens (e.g., pollen mites, pet hair) bind to IgE antibodies on mast cells
- mast cells release histamine, leukotrienes, tryptase, kinins, and prostaglandins
- histamine and leukotrienes bind to their respective receptors on target cells, causing symptoms like inflammation and bronchoconstriction
- antihistamines and leukotriene receptor agonists block these pathways to alleviate symptoms

Late Phase:
- eosinophils release cationic proteins and cytokines, contributing to tissue damage and chronic inflammation
- basophils enhance the response with histamine and other cytokines

71
Q

True or False: Food allergens (milk, eggs, soy, wheat), dust mites, and inhalent allergens such as pet dander most commonly cause allergic rhinitis in adults

A

False

They most commonly cause allergic rhinitis in infancy and childhood

72
Q

True or False: Pollen allergens become more significant in older children and adolescents

A

True

73
Q

True or False: There has been increasing evidence that dysbiosis of the gut microbiota is associated with atopy

A

True

74
Q

It has been hypothesized that dysbiosis causes abnormal allergic reactions by shifting the immune response toward a ______ (Th1/Th2) response and the production of IgE in allergic rhinitis.

A

Th2

75
Q

Differentiate a healthy gut vs. dysregulated gut microbiome and how it relates to the development of allergic rhinitis (AR)

A

Healthy Gut Microbiome (Left Side):
- Commensal bacteria: Contribute to the production of short-chain fatty acids (SCFAs).
- Mucus layer: Maintains a protective barrier.
- IgA secretion: Plasma cells produce IgA antibodies that protect against pathogens.
- T regulatory (Treg) cells maintain immune tolerance.
- ILC1 and IL-22 promote epithelial health and defense.

Dysregulated Gut Microbiome (Right Side):
- Non-commensal (pathogenic) bacteria: Increase, leading to epithelial damage and immune dysregulation.
- Th2 cell activation: Driven by IL-4 and IL-13, leading to the production of IgE antibodies.
- Mast cells and eosinophils: Trigger inflammatory responses associated with allergic conditions.
- Disrupted epithelial barrier: Leads to increased permeability and heightened immune activation.

Clinical Impact:
Normal Nasal Cavity: Linked to a balanced microbiome, minimal inflammation, and proper immune regulation.
Allergic Rhinitis: Associated with dysbiosis, IgE-mediated hypersensitivity, and excessive mucus production.

76
Q

Patients with allergic rhinitis (AR) have a reduced gut microbiome diversity, characterized by increased _____________ and decreased _______________

A

INCREASED Bacteroidetes

DECREASED Actinobacterium, Proteobacterium, and Escherichia coli

Note: Some slides also say decreased Firmicutes

77
Q

these indices measure the richness and evenness of microbial species in the gut, whereby lower values in AR patients suggest LESS gut diversity

A

Chao1 and Shannon

78
Q

Reduced levels of which microbiota phylum are linked to decreased production of beneficial metabolites, such as short-chain fatty acids (SCFAs), which are crucial for maintaining gut health and immune regulation

A

Firmicutes

79
Q

What might you notice upon physical examination of a patient with AR?

A
  • mouth breathing
  • frequent sniffling and/or throat clearing
  • dark circles under eyes
  • transverse supra-tip nasal crease (more common in children)
  • swelling of the nasal mucosa
  • thin, clear secretions
  • inferior nasal turbinates = maybe be blueish
  • tenderness upon sinus palpation (usually in chronic cases)
80
Q

True or False: Increased levels of Bacteroidetes are associated with inflammation and altered gut function

A

True

81
Q

True or False: Severe AR has significantly less gut microbiome diversity than moderate AR

A

False

No significant difference between their lack of gut diversity

82
Q

Symptoms of AR can be intermittent or persistent.

Differentiate the two.

A

Intermittent = < 4 days/week or < 4 weeks in duration

Persistent = > 4 days/week or > 4 weeks in duration

83
Q

What are common symptoms of nonallergic rhinitis?

A
  • nasal obstruction
  • clear rhinorrhea

Note: sneezing and itchy, watery eyes are NOT common

84
Q

True or False: It is advisable to ask patients with nonallergic rhinitis about over-the-counter nasal sprays, previous trauma, work exposure, or intranasal drug use

A

True

85
Q

With nonallergic rhinitis patients, it is important to pay attention to epistaxis (nosebleed), pain, and unilateral symptoms as these may be signs of ____________

A

neoplasm

86
Q

types of nonallergic rhinitis

A
  • viral rhinitis
  • occupational rhinitis
  • vasomotor rhinitis
  • NARES
  • rhinitis medicamentosa
87
Q

What is occupational rhinitis?

A
  • the nose may be affected by a variety of indoor or outdoor pollutants (e.g., dust, ozone, sulfur dioxide, cigarette smoke, garden sprays, wood particles)
  • characterized by dry nasal passages, reduced airflow, rhinorrhea, sneezing
88
Q

How can we limit exposure for those with occupational rhinitis?

A
  • mask
  • avoidance
  • improving ventilation
  • removing causal agent
89
Q

most common nonallergic rhinitis (NAR)

A

vasomotor rhinitis (VMR) aka “idiopathic rhinitis”

90
Q

True or False: Vasomotor rhinitis (VMR) is usually a seasonal pathology

A

False

It is usually perennial

91
Q

What are some triggers for vasomotor rhinitis?

A
  • strong odours
  • cold air exposure
  • alcohol consumption
  • spicy foods
92
Q

most common causes or rhinitis medicamentosa

A

oxymetazoline and phenylephrine

93
Q
A
94
Q
A
95
Q
A

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