ENT- Allergic Rhinitis, Chronic Nonallergic Rhinitis/Vasomotor Rhinitis

Question 1

Allergic Rhinitis- Epidemiology

Answer 1

–Affects 10-30% of children and adults in U.S.

–Prevalence is increasing – environmental changes

Question 2

Allergic Rhinitis- Risk factors

Answer 2

1. Family history atopy (atopic triad)
2. Male sex
3. Birth during pollen season
4. First born
5. Early use of antibiotics
6. Maternal smoking in first year of life
7. Indoor allergen exposure
8. Serum IgE > 100 IU/mL before age 6
9. Presence of allergen-specific IgE

Question 3

Etiology of Allergic Rhinitis

Answer 3

–Exposure to an airborne allergen in a predisposed person

–Activation of B-cell (humoral) and T-cell (cytotoxic) immune system responses

–Allergen-specific IgE responses cause release of inflammatory mediators

Question 4

Allergic Rhinitis- Pathophysiology

Answer 4

–Abnormal immune response to an environmental protein

Question 5

How do you classify allergic rhinitis

Answer 5

Intermittent vs. persistent and severity

Also whether it is seasonal or perennial (year round)

Question 6

Intermittent Allergic Rhinitis vs. persistent

Answer 6

intermittent: <4 days/week or less than 4 weeks

Persistent: >4 days/week and more than 4 weeks

Question 7

What criteria should be met to classify allergic rhinitis as moderate to severe?

Answer 7

Pt must have 1 or more of the following:

1. Sleep disturbance
2. impaired school/work performance
3. Impaired daily activities, leisure, and/or sport activities
4. Troublesome symptoms

**If patient has none of these symptoms then the allergic rhinitis would be classified as mild

Question 8

Allergic Rhinitis- Concomitant disorders

Answer 8

1. Allergic conjunctivitis
2. Sinusitis
3. Asthma
4. Atopic dermatitis
5. Eustachian tube dysfunction- Serous & acute OM

Question 9

What are clinical manifestations of allergic rhinitis?

Answer 9

1. Sneezing
2. Rhinorrhea
3. Nasal obstruction/congestion
4. Nasal itching (also palate & inner ear)
5. Postnasal drip (can cause sore throat and trigger cough)
6. Cough
7. Irritability
8. Fatigue
9. Eye itching, tearing, burning

Question 10

What are physical clinical manifestations of allergic rhinitis?

Answer 10

1. Infraorbital edema/darkening “allergic shiners”
2. Transverse nasal crease “allergic salute”
3. Nasal mucosa pale bluish color or pallor & turbinate edema
4. Clear rhinorrhea (nose or posterior pharynx)
5. Hyperplastic lymphoid tissue in posterior pharynx “cobblestoning”
6. TM retraction or serous fluid behind TM

Question 11

How is Allergic Rhinitis diagnosed?

Answer 11

*Based on clinical diagnosis- dont need any further diagnostic studies

• labs are usually normal
• Allergy skin testing

Serum IgE

Question 12

Allergic Rhinitis- Information regarding allergy skin testing

Answer 12

–Prick skin test – most commonly used

–Intradermal skin test – higher sensitivity

–Remember to discontinue medications

Question 13

Medication options for allergic rhinitis

Answer 13

1. Glucocorticoid nasal spray
2. Oral antihistimines
3. +/- decongestant if needed
4. Antihistimine nasal sprays
5. Combo glucocorticoid and antihistimine nasal spray
6. Mast cell stabilizer
7. Leukotriene receptor antagonist
8. Ipratropium bromide nasal (Atrovent)
9. Nasal decongestant sprays (Afrin)

Question 14

What are 1st, 2nd and 3rd generation oral antihistimine options used to treat allergic rhinitis?

Answer 14

•1st generation:

–Diphenhydramine (Benadryl)

–Chlorpheniramine (Chlor-Trimeton)

–Hydroxyzine (Vistaril)

•2nd/3rd generation

–Loratidine (Claritin)

–Cetirizine (Zyrtec)

–Fexofenadine (Allegra)

–Desloratadine (Clarinex)

–Levocetirizine (Xyzal)

*2nd/3rd generation often preferred over 1st line due to less side effects

Question 15

What antihistimine nasal spray options are recommended to help treat allergic rhinitis?

Answer 15

• Azelastine (Astepro)
• Olopatadine (Patanase)

**antihistamine nasal sprays are typically recommended if the patient primarily has nasal symptoms

Question 16

What are some Leukotriene receptor antagonists that can help treat allergic rhinitis?

Answer 16

• Montelukast (Singulair)
• Zafirlukast (Accolate)
• Zileuton (Zyflo)

given for pt with more severe allergies

***THESE ARE NOT FIRST LINE*****

Question 17

How does Ipratropium bromide nasal (Atrovent) help with allergic rhinitis?

Answer 17

Reduction of rhinorrhea

good for as needed tx

***Not first line***

Question 18

What are NOT good medication options to treat allergic rhinitis and why?

Answer 18

Systemic glucocorticoids (Oral, IM)

This is because it is hard to control response

Question 19

What patient education should a patient with allergic rhinitis be given?

Answer 19

1. Nasal saline irrigation
2. Allergen avoidance (use plastic covers on pillows/mattresses, using synthetic material instead of animal, remove dust collectors like carpets, air purifiers/dust filters)

Question 20

Allergic rhinitis- Refractory symptoms

Answer 20

1. Referral- allergist/immunologist
2. Immunotherapy- SQ vs. sublingual

Question 21

Etiology/pathogenesis of nonallergic rhinitis

Answer 21

–Abnormal autonomic regulation of innervation of nose

–Nasal eosinophilia without allergen sensitivity

Question 22

What are triggers of Nonallergic Rhinitis?

Answer 22

–Temperature changes

–Eating

–Exposure to odors / chemicals

–Alcohol use

Question 23

What is the clinical presentation of nonallergic rhinitis?

Answer 23

–Nasal congestion

–Postnasal drainage

–Boggy, edematous nasal turbinates – more erythematous

Question 24

How is nonallergic rhinitis diagnosed?

Answer 24

–Diagnosis of exclusion

–Absence of evidence for clinical allergy

Question 25

How is nonallergic rhinitis treated?

Answer 25

–Topical intranasal glucocorticoids

–Topical antihistamine (azelastine)