1. WHAT IS ALLERGIC RHINITIS HOW TO DIFFERENTITE NON AR WITH MALIGNANCY

2. INTRODUCTION Rhinitis : defined as inflammation of the nasal mucosa Rhinitis : defined as inflammation of the nasal mucosa Characterized by two or more of the following symptoms: Characterized by two or more of the following symptoms: nasal congestion nasal congestion rhinorrhea rhinorrhea sneezing sneezing itchy nose itchy nose Post nasal drip Post nasal drip These symptoms occur during two or more consecutive days for more than one hour on most days These symptoms occur during two or more consecutive days for more than one hour on most days

3. Introduction

4. Definition AR is clinically defined as a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation. AR is clinically defined as a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation. It is characterised by: It is characterised by: nasal itching, sneezing, rhinorrhea, and nasal congestion. nasal itching, sneezing, rhinorrhea, and nasal congestion. Ocular symptoms : allergic rhinoconjunctivitis (itching, redness and tearing of eyes) Ocular symptoms : allergic rhinoconjunctivitis (itching, redness and tearing of eyes) Others : itching of the palate, postnasal drip, and cough. Others : itching of the palate, postnasal drip, and cough.

5. Seasonal Seasonal -occurs certain time of the year -due to outdoor molds and pollens Perenniel Perenniel -occur throughout the year - due to indoor allergens, most commonly dust mite, cockroaches and indoor molds, animal dander.

6. EPIDEMIOLOGY The prevalence of self-reported AR The prevalence of self-reported AR 2% to 25% in children 2% to 25% in children 1% to greater than 40% in adults. 1% to greater than 40% in adults. The prevalence of confirmed AR in adults in Europe ranged from 17% to 28.5%. The prevalence of confirmed AR in adults in Europe ranged from 17% to 28.5%. The prevalence of allergic rhinitis is increasing in most countries in the world, and particularly in areas with low or medium levels of prevalence. The prevalence of allergic rhinitis is increasing in most countries in the world, and particularly in areas with low or medium levels of prevalence.

7. Classification

8. Cont’ AR also associated with asthma (15% to 38%) and is a risk factor of asthma. AR also associated with asthma (15% to 38%) and is a risk factor of asthma. Uncontrolled moderate-to-severe AR affects asthma control. Uncontrolled moderate-to-severe AR affects asthma control.

9. ETIOLOGY Classified as Classified as Precipitating factors Precipitating factors Predisopsing factors Predisopsing factors

10. PRECIPITATING FACTORS  Aerobiological flora Allergens present in the environment Allergens present in the environment House dust and dust mites House dust and dust mites Feathers Feathers Tobacco smoke Tobacco smoke Industrial chemicals Industrial chemicals Animal dander Animal dander  Nasal physiology Disturbances in normal nasal cycle Disturbances in normal nasal cycle

11. PREDISPOSING FACTORS Genetic Genetic - Multiple gene interactions are responsible for allergic phenotype phenotype - 50% of allergic rhinitis patients have a positive family history of allergic rhinitis of allergic rhinitis Endocrine Endocrine - Puberty - Pregnant states and post partum stages - Menopausal

12. PREDISPOSING FACTORS Physical Physical -Degree of pollution of air - Humidity and temperature differences - Temperature changes Age & sex Age & sex IgA deificiency IgA deificiency

13. COMMON ALLERGENS Pollens Pollens Spring tree pollens(maple alder, birch) Spring tree pollens(maple alder, birch) Summer : grass pollent (bluegrass, sheep shorell etc Summer : grass pollent (bluegrass, sheep shorell etc Autums: weed pollen (ragweed) Autums: weed pollen (ragweed) Molds Molds Penicillium, cladosporium etc Penicillium, cladosporium etc Insects Insects Cockroaches, house flies, fleas, bed bugs Cockroaches, house flies, fleas, bed bugs Animals Animals Cats. Dogs. Horse, monkeys, rats, rabbits etc Cats. Dogs. Horse, monkeys, rats, rabbits etc Dust mites Dust mites dermatophagoides dermatophagoides Ingestants Ingestants Nuts, fish, eggs, milk etc Nuts, fish, eggs, milk etc

14. PATHOPHYSIOLOGY Phase 1 : Sensitization to allergens Phase 1 : Sensitization to allergens In susceptible individuals, exposure to certain foreign proteins leads to allergic sensitization, which is characterized by the production of specific IgE directed against this proteins. Phase 2 : Early and late reactions Phase 2 : Early and late reactions Produced antigen-specific IgE binds to high-affinity IgE receptors on mast cells or basophils, which are present on the nasal mucosa. When the specific protein is inhaled into the nose, it can bind to the IgE on the mast cells, leading to immediate and delayed release of a number of mediators.

15. CONT’ Sneezing Rhinorrhea Develops in 30 minutes then disappear Due to release of chemical mediators by mast cells such as histamine, prostaglandin and leukotrienes in response to exposure to allergens (type I hypersensitivity). Immediate or early reaction Chronic nasal blockage, congestion approximately 6 hours after exposure to allergens and subsides slowly Due to infiltration of inflammatory cells at site of antigen deposition eosinophil chemotaxis is the main mechanism in the late reaction Delayed or late reaction

17. PHYSICAL EXAMINATION Allergic shiners: dark discoloration beneath the eyes as a result of obstruction of lymphatic and venous drainage, chronic nasal obstruction, and suborbital edema. Allergic shiners: dark discoloration beneath the eyes as a result of obstruction of lymphatic and venous drainage, chronic nasal obstruction, and suborbital edema. Dennie-Morgan lines: creases in the lower eyelid radiating outward from the inner canthus; caused by spasm in the muscles around the eye as a result of chronic congestion and stasis of blood. Dennie-Morgan lines: creases in the lower eyelid radiating outward from the inner canthus; caused by spasm in the muscles around the eye as a result of chronic congestion and stasis of blood.

18. PHYSICAL EXAMINATION Allergic salute : a gesture characterized by rubbing the nose with the palm of the hand upward to decrease itching and temporarily open the nasal passages. Allergic salute : a gesture characterized by rubbing the nose with the palm of the hand upward to decrease itching and temporarily open the nasal passages. Allergic crease: transverse crease near the tip of the nose,secondary to rubbing. Allergic crease: transverse crease near the tip of the nose,secondary to rubbing. Nasal mucosa may appear pale and/or edematous; mucoid or watery material may be seen in the nasal cavity; check for nasal polyps, septal deviation. Nasal mucosa may appear pale and/or edematous; mucoid or watery material may be seen in the nasal cavity; check for nasal polyps, septal deviation.

19. PHYSICAL EXAMINATION Adenoid facies- defined as a long, thin face with malar hypoplasia, high-arched palate, narrow maxillary arch, and angle class II malocclusion. Due to chronic nasal obstruction Adenoid facies- defined as a long, thin face with malar hypoplasia, high-arched palate, narrow maxillary arch, and angle class II malocclusion. Due to chronic nasal obstruction

20. NON AR

21. NON ALLERGIC RHINITIS is applied to a diagnosis any nasal condition in which the are identical to those seen in rhinitis but an allergic aetiology has been excluded. is applied to a diagnosis any nasal condition in which the are identical to those seen in rhinitis but an allergic aetiology has been excluded. Occur more frequently in adults than in children. Occur more frequently in adults than in children. More likely to be perennial than seasonal. More likely to be perennial than seasonal.

22. Non allergic rhinitis can be classified Idiopathic rhinitis (also referred to as vasomotor rhinitis, or nonallergic noninfectious rhinitis (NANIPER) Idiopathic rhinitis (also referred to as vasomotor rhinitis, or nonallergic noninfectious rhinitis (NANIPER) Non-allergic occupational rhinitis Non-allergic occupational rhinitis Hormonal rhinitis Hormonal rhinitis Drug-induced rhinitis Drug-induced rhinitis Other forms (non allergic rhinitis with eosinophilia syndrome (NARES), rhinitis due physical and chemical factors),food-induced rhinitis, emotion induced rhinitis, atrophic rhinitis) Other forms (non allergic rhinitis with eosinophilia syndrome (NARES), rhinitis due physical and chemical factors),food-induced rhinitis, emotion induced rhinitis, atrophic rhinitis)

23. VASOMOTOR RHINITIS

24. Etiology is unknown, however attempts have been made to differentiate idiopathic rhinitis on basis hyperactivity to histamine, methacholine, cold dry air or capsaicin. Etiology is unknown, however attempts have been made to differentiate idiopathic rhinitis on basis hyperactivity to histamine, methacholine, cold dry air or capsaicin. None of the test have been able to differentiate it from other forms of rhinitis None of the test have been able to differentiate it from other forms of rhinitis

25. VASOMOTOR RHINITIS Vasomotor rhinitis is characterized by prominent symptoms of nasal obstruction, rhinorrhea, and congestion. Vasomotor rhinitis is characterized by prominent symptoms of nasal obstruction, rhinorrhea, and congestion. These symptoms are excessive at times and are exacerbated by certain odors (e.g. perfumes, cigarette smoke, paint fumes, inks), alcohol, spicy foods, emotions, and environmental factors such as temperature, barometric pressure changes, and bright lights. These symptoms are excessive at times and are exacerbated by certain odors (e.g. perfumes, cigarette smoke, paint fumes, inks), alcohol, spicy foods, emotions, and environmental factors such as temperature, barometric pressure changes, and bright lights. Patients with vasomotor rhinitis are further divided into two subgroups: Patients with vasomotor rhinitis are further divided into two subgroups: “runners,” who demonstrate “wet” rhinorrhea “runners,” who demonstrate “wet” rhinorrhea “dry” patients, who exhibit nasal obstruction and airflow resistance with minimal rhinorrhea “dry” patients, who exhibit nasal obstruction and airflow resistance with minimal rhinorrhea

26. Occupational rhinitis Arises from airborne agents at workplace. Arises from airborne agents at workplace. Agents do not act through immune-mediated mechanism. They are direct irritants to the nasal mucosa and cause non-allergic hyper- responsive reactions. Agents do not act through immune-mediated mechanism. They are direct irritants to the nasal mucosa and cause non-allergic hyper- responsive reactions.

27. RISK FACTORS Risk factors for developing occupational rhinitis are: Risk factors for developing occupational rhinitis are: o Exposure{intensity & duration} o Atopy o Smoking o Over 205 different chemicals entities identified, including cigarette smoke and chemicals and solvents like chlorine, metal salts, latex, glues and wood dusts

28. Symptoms includes sneezing, nasal blockage and rhinorrhea. Symptoms includes sneezing, nasal blockage and rhinorrhea. Patients also usually present with concurrent occupational asthma and conjuctivitis. Patients also usually present with concurrent occupational asthma and conjuctivitis. Diagnosis is based on history or results of nasal provocation with stimulus. Diagnosis is based on history or results of nasal provocation with stimulus.

29. ATROPHIC RHINITIS

30. is a chronic nasal disease is a chronic nasal disease It is characterised by the formation of thick dry crusts in a roomy nasal cavity, which has resulted from progressive wasting away or decrease in size (atrophy) of the mucous nasal lining ( mucosa ) and underlying bone. It is characterised by the formation of thick dry crusts in a roomy nasal cavity, which has resulted from progressive wasting away or decrease in size (atrophy) of the mucous nasal lining ( mucosa ) and underlying bone. Divided into:- Divided into:- 1. Primary 1. Primary 2. Secondary

31. PRIMARY ATROPHIC RHINITIS Predominantly in women & is characterized by progressive atrophy of the nasal mucosa & underlying bone of the turbinates. Predominantly in women & is characterized by progressive atrophy of the nasal mucosa & underlying bone of the turbinates. Leads to formation of thick crusts, which leave a constant foul smell ( ozaena) in nose. Leads to formation of thick crusts, which leave a constant foul smell ( ozaena) in nose. Nasal cavities are enlarged & there is sensation of nasal congestion. Nasal cavities are enlarged & there is sensation of nasal congestion. Thought to be due to infection with klebsiella ozaenae. Thought to be due to infection with klebsiella ozaenae. Common in China, India and Middle East Common in China, India and Middle East

32. Causes of Primary Atrophic Rhinitis H - Hereditary H - Hereditary E - Endrocrine imbalance E - Endrocrine imbalance R - Racial factor R - Racial factor N - Nutritional deficiency N - Nutritional deficiency I - Infections I - Infections A- Autoimmune process A- Autoimmune process

33. SECONDARY ATROPHIC RHINITIS This is the most common form of atrophic rhinitis seen in developed countries. This is the most common form of atrophic rhinitis seen in developed countries. Common causes of secondary atrophic rhinitis include: Common causes of secondary atrophic rhinitis include: 1. Surgical procedures involving nose and paranasal sinuses They include turbinectomies, sinus surgeries, maxillectomy,etc. They include turbinectomies, sinus surgeries, maxillectomy,etc. 2. Irradiation 3. Trauma 4. Granulomatous diseases: Include Sarcoidosis, Leprosy and Rhinoscleroma and Rhinoscleroma 5. Infections: This includes tuberculosis and syphilis

34. CLINICAL PRESENTATION Greenish–yellow or brownish-black crusts Greenish–yellow or brownish-black crusts Wide nasal cavity Wide nasal cavity Atrophic mucosa & dry Atrophic mucosa & dry Fetid secretion & crusts (Ozena) Fetid secretion & crusts (Ozena) Anosmia Anosmia Nasal obstruction Nasal obstruction Epistaxis, may occur when the dried discharge (crusts) are removed. Epistaxis, may occur when the dried discharge (crusts) are removed. Septal perforation and dermatitis of nasal vestibule can occur. The nose may show a saddle-nose deformity. Septal perforation and dermatitis of nasal vestibule can occur. The nose may show a saddle-nose deformity.

35. SIGNS : ANTERIOR RHINOSCOPY: PALE & ATROPHIC MUCOSA GREENISH FOUL SMELLING CRUSTS ATROPHIED TURBINATES

36. HORMONAL RHINITIS

37. is often associated with pregnancy in particular, although puberty is also known to induce the symptoms of rhinitis. is often associated with pregnancy in particular, although puberty is also known to induce the symptoms of rhinitis. HR usually manifests in in the last trimester as a consequence of progesterone stimulation and will continue throughout pregnancy, usually resolve 2 weeks after delivery. HR usually manifests in in the last trimester as a consequence of progesterone stimulation and will continue throughout pregnancy, usually resolve 2 weeks after delivery. Hypothyroidism is also known to cause hormonal rhinitis. In hypothyroidism, increase TSH release causes edema of the turbinates. Hypothyroidism is also known to cause hormonal rhinitis. In hypothyroidism, increase TSH release causes edema of the turbinates. Nasal congestion and rhinorrhea are the most common symptoms of HR. Nasal congestion and rhinorrhea are the most common symptoms of HR.

38. NON ALLERGIC RHINITIS WITH EOSINOPHILIC SYNDROME

39. NARES was originally introduced by Mullarkey and colleagues, who characterized the condition on the basis of a presence of > 20% eosinophils in nasal smears of symptomatic patients with perennial sneezing attacks, a profuse watery rhinorrhoea, nasal pruritis, incomplete nasal obstruction and occasional loss of smell. NARES was originally introduced by Mullarkey and colleagues, who characterized the condition on the basis of a presence of > 20% eosinophils in nasal smears of symptomatic patients with perennial sneezing attacks, a profuse watery rhinorrhoea, nasal pruritis, incomplete nasal obstruction and occasional loss of smell. A marked feature of the disease is the lack of evidence of allergy, as indicated by negative skin prick tests and/or absence of serum IgE antibodies to specific allergens. A marked feature of the disease is the lack of evidence of allergy, as indicated by negative skin prick tests and/or absence of serum IgE antibodies to specific allergens.

40. Etiology is unknown, however, NARES is believed to be associated with -sampter’s triad (ASA triad) Etiology is unknown, however, NARES is believed to be associated with -sampter’s triad (ASA triad) Triad of nasal polyposis, intrinsic asthma, intolerance to aspirin. Triad of nasal polyposis, intrinsic asthma, intolerance to aspirin. This is due to the fact that NARES patients frequently develop nasal polyps and asthma later in life. This is due to the fact that NARES patients frequently develop nasal polyps and asthma later in life. Abnormal prostaglandin metabolism has been also implicated as cause of NARES. Abnormal prostaglandin metabolism has been also implicated as cause of NARES. However, eosinophil counts are elevated in 20% of nasal smears of general population and not everyone with eosinophilias has symptoms of rhinitis. However, eosinophil counts are elevated in 20% of nasal smears of general population and not everyone with eosinophilias has symptoms of rhinitis. The presence of eosinophilia in NARES is an important predictor for response to treatment with topical anti-inflammatory therapy, such as intranasal steroids with or without antihistamines. The presence of eosinophilia in NARES is an important predictor for response to treatment with topical anti-inflammatory therapy, such as intranasal steroids with or without antihistamines.

41. DRUG INDUCED RHINITIS

42. Several common medications may induce rhinitis when administered topically or orally. Several common medications may induce rhinitis when administered topically or orally. Drugs can be divided into pharmacologic or aspiring hypersensitivity. Drugs can be divided into pharmacologic or aspiring hypersensitivity.

43. Here is that include many of the drugs that are common causes rhinitis. Cocaine Cocaine Topical nasal decongestants Topical nasal decongestants phosphodiesterase type-5 inhibitors (PDE-5)—Sildenafi phosphodiesterase type-5 inhibitors (PDE-5)—Sildenafi Alpha-adrenoceptor antagonists Alpha-adrenoceptor antagonists Reserpine Reserpine Hydralazine Hydralazine Angiotensin-converting enzyme inhibitors Angiotensin-converting enzyme inhibitors Beta-blockers Beta-blockers Methyldopa Methyldopa Guanethidine Guanethidine Phentolamine Phentolamine Oral contraceptives Oral contraceptives Non steroidal anti- inflammatory medications Non steroidal anti- inflammatory medications Aspirin Aspirin Psychotropic agents Psychotropic agents Thioridazine Thioridazine Chlordiazepoxide Chlordiazepoxide Chlorpromazine Chlorpromazine Amitriptyline Amitriptyline Perphenazine Perphenazine Alprazolam Alprazolam

44. DRUG INDUCED RHINITIS Intolerance to aspirin and/or NSAIDS is unpredictable. Intolerance to aspirin and/or NSAIDS is unpredictable. It is predominately produces rhinorrhea but may be a part of a ASA triad complex involving hyperplastic rhinosinusitis, nasal polyps and asthma. It is predominately produces rhinorrhea but may be a part of a ASA triad complex involving hyperplastic rhinosinusitis, nasal polyps and asthma. In contrast, intolerance to ACE inhibitors, methyldopa or oral contraceptives, which is less common than aspirin intolerance, leads predominantly to nasal blockage. In contrast, intolerance to ACE inhibitors, methyldopa or oral contraceptives, which is less common than aspirin intolerance, leads predominantly to nasal blockage. Many common antihypertensive medication and psychiatric medications cause rhinitis. Many common antihypertensive medication and psychiatric medications cause rhinitis.

45. RHINITIS MEDICAMENTOSA

46. Persistent overuse of the topical nasal vasoconstrictors also leads to nasal decongestion by a mechanism involving a rebound effect following withdrawal of these drugs. Persistent overuse of the topical nasal vasoconstrictors also leads to nasal decongestion by a mechanism involving a rebound effect following withdrawal of these drugs. Excessive use of these agents may also lead to nasal hyper-reactivity and hypertrophy of the nasal mucosa known as rhinitis medicamentosa. Excessive use of these agents may also lead to nasal hyper-reactivity and hypertrophy of the nasal mucosa known as rhinitis medicamentosa. Nasal topical decongestants ( oxymetazoline, naphazoline, xylometazoline) Nasal topical decongestants ( oxymetazoline, naphazoline, xylometazoline)

47. RHINITIS DUE TO PHYSICAL AND CHEMICAL FACTORS Nasal symptoms similar to those of rhinitis can be induced by physical and chemical factors in individuals with sensitized nasal mucous membranes. Nasal symptoms similar to those of rhinitis can be induced by physical and chemical factors in individuals with sensitized nasal mucous membranes. Cold, dry air has been shown to lead to a condition known as skier's nose, in which rhinorrhoea features prominently. Cold, dry air has been shown to lead to a condition known as skier's nose, in which rhinorrhoea features prominently. Exposureto chemicals, particularly air pollutants derived from cigarette smoke and liquid petroleum fuels, have also been shown to directly exacerbate symptoms of rhinitis. Exposureto chemicals, particularly air pollutants derived from cigarette smoke and liquid petroleum fuels, have also been shown to directly exacerbate symptoms of rhinitis.

48. FOOD-INDUCED RHINITIS Certain foods and alcoholic beverages can induce nonallergic rhinitis, although the underlying mechanisms are largely unknown. Certain foods and alcoholic beverages can induce nonallergic rhinitis, although the underlying mechanisms are largely unknown. Alcoholic beverages are thought to induce symptoms as a result of vasodilation. Alcoholic beverages are thought to induce symptoms as a result of vasodilation. Hot and spicy foods, in particular, which contain capsaicin lead to a watery rhinorrhoea termed 'gustatory rhinitis', resulting of the capsaicin stimulating the sensory nerves to release neuropeptides and tachykinins. Hot and spicy foods, in particular, which contain capsaicin lead to a watery rhinorrhoea termed 'gustatory rhinitis', resulting of the capsaicin stimulating the sensory nerves to release neuropeptides and tachykinins. It can be relieved by ipratropium bromide nasal spray (an anticholinergic), a few minutes before meals. It can be relieved by ipratropium bromide nasal spray (an anticholinergic), a few minutes before meals.

49. EMOTIONAL RHINITIS Nose may react to several emotional stimuli. Nose may react to several emotional stimuli. Psychological states like anxiety, tension, hostility, humiliation and grief are all known to cause rhinitis. Psychological states like anxiety, tension, hostility, humiliation and grief are all known to cause rhinitis. Treatment is proper counseling for psychological adjustment. Treatment is proper counseling for psychological adjustment. Imipramine, which has both antidepressant and anticholinergic effects has been found useful. Imipramine, which has both antidepressant and anticholinergic effects has been found useful.

50. RED FLAG IN AR Unilateral rhinorrhea-should exclude csf leak, presence of a malignancy, an antrochoanal polyp or a foreign body, or simply septal deviation. Unilateral rhinorrhea-should exclude csf leak, presence of a malignancy, an antrochoanal polyp or a foreign body, or simply septal deviation. Unilateral symptoms of obstruction with blood stained discharge Unilateral symptoms of obstruction with blood stained discharge Persistent (>3weeks) unilateral symptoms of obstruction Persistent (>3weeks) unilateral symptoms of obstruction Unilateral or bleeding polyps Unilateral or bleeding polyps Polyps in children Polyps in children Paraesthesia of cheek Paraesthesia of cheek Persistent unexplained epistaxis Persistent unexplained epistaxis

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