SM_184a: Allergic Rhinitis Flashcards
Rhinitis is defined as _____
Rhinitis is defined as inflammation of the mucous membranes, mostly in the nose but also in eyes, throat, sinus, and ears, giving rise to symptoms of nasal congestion, rhinorrhea, sneezing, and pruritis
Describe the pathophysiology of rhinitis
- Genetically predisposed individual comes in contact with an antigen
- Sensitization: allergic sensitization occurs through interaction of antigen-presenting cells, and T cells induce B cells cells to make plasma cells that release IgE
- Re-exposure: preformed IgE on mast cells comes in contact with antigen again, causing an inflammatory cascade (immediate and late phase)
In the sensitization phase of rhinitis pathophysiology, ________
In the sensitization phase of rhinitis pathophysiology, allergic sensitization occurs through interaction of antigen presenting cells, and T cells secrete IL-4 and IL-13 to induce B cells to make plasma cells that release IgE
In the re-exposure phase of rhinitis pathophysiology, _______
In the re-exposure phase of rhinitis pathophysiology, preformed IgE on mast cells comes in contact with the antigen again, causing an inflammatory cascade
- Immediate (minutes): preformed, quickly made
- Late phase (4-8 hours)
The most common preformed mediator released during the immediate phase of rhinitis is ______
The most common preformed mediator released during the immediate phase of rhinitis is histamine
(also tryptase, chymase, kinins, and heparin)
Early phase reaction symptoms of rhinitis include ______, ______, and ______
Early phase reaction symptoms of rhinitis include sneezing, itching, and rhinorrhea and congestion
Quickly made mediators released during the immediate phase of rhinitis include
Quickly made mediators released during the immediate phase of rhinitis include
- Leukotrienes (LTC4, LTD4): increase mucous production
- Prostaglandin D2: causes vasodilation
- Platelet activating factor: eosinophil chemotaxis and cell migration
Late phase mediators released in rhinitis include:
- *
Late phase mediators released in rhinitis include:
- Cytokines: inflammatory (IL-1, IL-6, TNF-alpha), promote IgE (IL-4, IL-13), and promote eosinophils (IL-5, IL-3, GM-CSF)
- Chemokines: RANTES, eotaxin
Late phase of rhinitis involves symptoms of _____ and _____
Late phase of rhinitis involves symptoms of more nasal congestion and rhinorrhea (less sneeze and itch)
(lead to more fatigue and exhaustion)
Physical manifestations of rhinitis are:
Physical manifestations of rhinitis are:
- Mucous gland secretion -> rhinorrhea
- Vasodilation -> congestion
- Vascular permeability -> congestion and rhinorrhea
- Neural stimulation -> sneezing and itching
How is the diagnosis of rhinitis made?
- History
- Physical exam
- IgE testing to aeroallergens: skin testing (pricks and intradermals), blood testing (specific IgE to aeroallergens)
Describe elements of the history important for a diagnosis of rhinitis
- Symptoms: pattern (location where symptoms occur), chronicity, occupational
- Quality of life: rhinitis severity, associated symptoms
Describe physical exam findings consistent with rhinitis
- Edenatous nasal mucosa
- Clear or colorful secretions
- Nasal polyps / deviated septum
- Post-nasal drip and cobblestoning
- Retracted ear drums
- Allergic shiners
- Dennie Morgan lines (creases under the lower eyelid)
- Nasal crease (from constantly rubbing the nose upward)
- Adenoid facies
______ edematous nasal mucosa is indicative of allergic rhinitis
Pale, boggy edematous nasal mucosa is indicative of allergic rhinitis
_____ edematous nasal mucosa is indicative of non-allergic, infectious
Erythematous edematous nasal mucosa is indicative of non-allergic, infectious
______ edematous nasal mucosa is indicative of rhinitis medicamentosa (overuse of nasal decongestants)
Beefy, red, swollen edematous nasal mucosa is indicative of rhinitis medicamentosa (overuse of nasal decongestants)
____ secretions can occur in allergic or non-allergic rhinitis
Clear secretions can occur in allergic or non-allergic rhinitis
(can also occur in viral infections or CSF fluid)
(colorful secretions are more often infectious)
Nasal polyps are _____
Nasal polyps are benign shiny pearl-like outgrowths in the nasal cavity
Bilateral nasal polyps are associated with _____, _____, and _____
Bilateral nasal polyps are associated with Samter’s triad (asthma, aspirin sensitivity, and nasal polyps), cystic fibrosis, and allergic fungal sinusitis
Unilateral nasal polyps are associated with _____
Unilateral nasal polyps are associated with nasopharyngeal cancer
Nasal septal perforation can be caused by _____, _____, _____, and _____
Nasal septal perforation can be caused by previous surgery, trauma, cocaine use, connective tissue disease such as Wegners or sarcoidosis
Main causes of rhinitis are:
Main causes of rhinitis are:
- Allergic
- Non-allergic: vasomotor / irritant rhinitis, rhinitis medicamentosa
- Mixed rhinitis (allergic + non-allergic): most common
- Other: pregnancy-related, connective tissue disease-related, medications
_____ is the symptom unique to allergic rhinitis
Nasal itch is the symptom unique to allergic rhinitis
(allergic rhinitis caused by aeroallergens and results in poor sleep and fatigue)
Non-allergic rhinitis involves onset at ____ age, is associated with _____ itching/sneezing, and occurs _____
Non-allergic rhinitis involves onset at older age, is associated with less itching/sneezing, and occurs year-round
(triggers: strong smells, smoke, change in temperature and barometric pressure, alcohol, gustatory rhinitis)
Describe which conditions comprise “other rhinitis”
- CPAP induced: treated by humidifying air, nasal antihistamine, and/or nasal steroids
- Medication induced (rhinitis medicamentosa): caused by overuse of nasal decongestants / cocaine
- Pregnancy-related: starts after 2nd month of gestation and resolves 2 weeks after delivery
- Atrophic: due to thinning of nasal mucosa due to age or recurrent injury, symptoms are congestion/crusting/persistent bad smeel, treatment is nasal rinse sometimes w/ topical antibiotics
- Connective tissue disease (Wegners or sarcoidosis)
Name allergens causing allergic rhinitis
- Seasonal: pollen
- Dust mite
- Cats
- Dogs
- Cockroaches
- Mold (indoor/outdoor)
_____ is the preferred method of aeroallergen testing
Skin testing is the preferred method of aeroallergen testing
(aeroallergen sensitization can occur as early as age 2)
______ has a sensitivity of 70-75% compared to skin testing
IgE testing has a sensitivity of 70-75% compared to skin testing
- Variable results due to potency of allergens on support system
- Cross-reactivity of other epitopes and glycoproteins with aeroallergens
- Too much IgE can alter results
Treatment for allergic rhinitis includes _____, _____, and _____
Treatment for allergic rhinitis includes avoidance, medications, and immunotherapy
(avoidance includes pet dander and dust mite avoidance)
_____ are the best medication to treat allergic rhinitis because they _____
Nasal steroids are the best medication to treat allergic rhinitis because they block both the early and late phase mediators of inflammation
(especially moderate to severe seasonal allergic rhinitis, may help ocular symptoms)
(side effects: may increase ocular pressure, cataract formation, and growth reduction in children)
Other options for treatment of allergic rhinitis include _____, _____, and _____
Other options for treatment of allergic rhinitis include
- Oral antihistamines (1st, 2nd gen): 1st gen cross BBB and cause sedation, lack specificity and bind to other receptors causing more side effects, and increase risk of dementia
- Intranasal antihistamines (azelastine, olapatidine): higher tissue levels in nose and relieve congestion, some systemic absorption so cause sedation and need to be stopped before skin testing
- Leukotriene receptor antagonists (montelukast, zafirlukast): may be more helpful in patients with aspirin sensitivity or exercise-induced asthma
- Intranasal cromolyn: effect for some in allergic rhinitis prevention and treatment
_____ are the most effective form of immunotherapy for allergic rhinitis
Subcutaneous allergy shots are the most effective form of immunotherapy for allergic rhinitis
- Building phase and maintenance phase
- May prevent developmnent of sensitization to new aeroallergens
- May decrease risk of developing asthma, especially in children
(sublingual tablets approved for grass, ragweed, and dust mite)
Common comorbidities of allergic rhinitis include _____, _____, _____, _____, and _____
Common comorbidities of allergic rhinitis include sinusitis, asthma, conjunctivitis, Eustachian tube dysfunction, and obstructive sleep apnea
- What is the diagnosis?
- What test do you perform?
- What is the best medication to use?
- She has allergic rhinitis to pollen specifically ragweed
- Do skin testing
- Prescribe nasal steroids
- What is the diagnosis?
- What is the patient using too much of?
- Rhinitis medicamentosa
- Patient is overusing topical nasal decongestants (should not be used for more than 3 consecutive days)
- What are the pearly white outgrowths?
- What medication might you be concerned about giving this patient?
- The pearly outgrowths are nasal polyps
- Wheezing indicates the patient has asthma, so aspirin and/or NSAIDs can cause asthma exacerbation (concerned he may have Samter’s triad)
