SM_184a: Allergic Rhinitis Flashcards by Nathan Shlobin

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

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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)

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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

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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)

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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)

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Early phase reaction symptoms of rhinitis include ______, ______, and ______

Early phase reaction symptoms of rhinitis include sneezing, itching, and rhinorrhea and congestion

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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

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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

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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)

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Physical manifestations of rhinitis are:

Mucous gland secretion -> rhinorrhea
Vasodilation -> congestion
Vascular permeability -> congestion and rhinorrhea
Neural stimulation -> sneezing and itching

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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)

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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

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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

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______ edematous nasal mucosa is indicative of allergic rhinitis

Pale, boggy edematous nasal mucosa is indicative of allergic rhinitis

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_____ edematous nasal mucosa is indicative of non-allergic, infectious

Erythematous edematous nasal mucosa is indicative of non-allergic, infectious

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______ 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:

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

1. What is the diagnosis? 2. What test do you perform? 3. What is the best medication to use?

1. She has allergic rhinitis to pollen specifically ragweed 2. Do skin testing 3. Prescribe nasal steroids

1. What is the diagnosis? 2. What is the patient using too much of?

1. Rhinitis medicamentosa 2. Patient is overusing topical nasal decongestants (should not be used for more than 3 consecutive days)

1. What are the pearly white outgrowths? 2. What medication might you be concerned about giving this patient?

1. The pearly outgrowths are nasal polyps 2. Wheezing indicates the patient has asthma, so aspirin and/or NSAIDs can cause asthma exacerbation (concerned he may have Samter's triad)