By: Saad A. Al-Saleh Khalid A. Al-Rabeeah Rhinitis By: Saad A. Al-Saleh Khalid A. Al-Rabeeah

Objectives Definition Aetiology Types Clinical Features Investigations Management Summary

Definition It is a disorder in which there are episodes of nasal congestion, watery nasal discharge and sneezing. It can be divided into: Seasonal Rhinitis. Perenial Rhinitis.

Aetiology Sneezing, increased secretion and change in mucosal blood flow are mediated by: Efferent nerve fibres. Released mediators.

Aetiology Parasympathetic stimulation causes increased mucous production and vasodilates blood vessels found in the mucosa, while sympathetic stimulation causes vasoconstriction of these vessels.

Aetiology Allergic rhinitis develops as a result of interaction between inhaled allergen and IgE antibody present on the surface of mast cells. Histamine causes increase permeability of the epithelium. Histamine causes sneezing. Cysteinyl leukotriens and vasodilator prostaglandins (PGD2, PGE2 and PGI2) released from mast cells, eosinophils and macrophages are potent in causing nasal blockage.

Seasonal Rhinitis It is often called “hay fever”. Most common of all allergic diseases. Nasal irritant, sneezing and watery rhinorrhea are most common symptoms. 20% may suffer from seasonal attacks of asthma. Usually caused by grass pollens.

Perennial Allergic Rhinitis Same symptoms but continuous and less severe. The major cause is the fecal particles of house-dust mite. Domestic pets also causes allergic symptoms.

Perennial Non-Allergic Rhinitis No extrinsic allergic cause. Eosinophilic granulocyte are present in nasal secretions. Aspirin and NSAIDs intolerance is found in this group.

Vasomotor Rhinitis No allergy nor eosinophilia in nasal secretions. They may suffer from non-specific nasal hyperreactivity that is due to an imbalance of the autonomic nervous system innervating the erectile tissue in the mucosa.

Severe Case of Rhinitis !!

Clinical Features

Clinical Features OR SYMPTOMS

Clinical Features Symptoms: Watery rhinorrhoea. Repetitive sneezing. Nasal obstruction. Pruritic (itchy) eyes, ears, nose or throat. Increased lacrimation.

Clinical Features

Clinical Features

SIGNS

Clinical Features Signs: Swollen nasal mucosa. Nasal polyps may be seen. Breathing from mouth. Injected sclerae. Allergic shiners (darkened areas under the lower eyelids thought to result from venous pooling of blood). Allergic salute ??!!

Clinical Features

Investigations 1. Skin prick test (SPT):

Investigations 2. RadioAllergoSorbent Test (RAST): Used if skin prick test cannot be used e.g. in children or the allergen is not available. Measures allergen-specifec IgE in serum.

Management Allergen Avoidance: Identification and avoidance of the causal allergen. Removal of carpets and soft toys from the bedroom. Careful vacuum-cleaning of carpets, mattresses, furniture & beds every week. use of allergen-impermeable (water-vapour permeable) covers for bed sheets.

Management Antihistamines: Histamine is a major mediator involved in the development of allergic rhinitis symptoms. 2nd generation drugs better (astemizole, loratadine, terfenadine, azelastine, etc..) Reduce nasal symptoms such as itching, sneezing and watery rhinorrhoea but have less effect on nasal blockage.

Management Intranasal Steroids: Reduces cytokine, chemokine release and inflammatory cells within the nasal mucosa. Reduces nasal blockage, rhinorrhoea, sneezing and itching. Beclomethasone and budesonide are the most cost-effective sprays* *Scadding GK. Intranasal steroid sprays in the treatment of rhinitis is one better than another? J Laryngol Otol. 2004 May;118(5):395-6.

Management Intranasal Steroids VS Antihistamines: A meta-analysis of 2267 patient proved that Intranasal corticosteroids produced significantly greater relief than oral anti-histamines in all nasal symptoms & should be used as 1st line of treatment for allergic rhinitis* A recent review article concluded that non-allergic rhinitis is better treated by azelastine nasal spray** *Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ. 1998 Dec 12;317(7173):1624-9. **Ciprandi G. Treatment of nonallergic perennial rhinitis. Allergy. 2004;59 Suppl 76:16-22; discussion 22-3.

Management Leukotriene receptor antagonists: Zafirlukast, Montelukast, etc.. As effective as antihistamines*. Less effective than nasal corticosteroids*. A non-steroidal oral alternative in the treatment of patients with both allergic rhinitis and asthma. *Wilson AM, O'Byrne PM, Parameswaran K. Leukotriene receptor antagonists for allergic rhinitis: a systematic review and meta-analysis. Am J Med. 2004 Mar 1;116(5):338-44.

Management Decongestants: Topical decongestants (xylometazoline) are very effective in the treatment of nasal obstruction compared to oral (pseud-oephedrine). Topical decongestants >10 days cause tachyphylaxis, rebound swelling of the nasal mucosa, and drug-induced rhinitis (rhinitis medicamentosa). Used with other drugs not alone.

Management Cromones (e.g. sodium nedocromil): Anti-inflammatory effect. inferior to drugs such as antihistamines and steroids. Not considered a major therapeutic option in the treatment of allergic rhinitis.

Summary Rhinitis is a common disease encountered in family practice. Sneezing, watery rhinorrhea and nasal blockage. It can be allergic or non-allergic. Identification & avoidance of allergen. Intranasal steroids sprays regarded as 1st line of treatment.

Questions?

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