1. ALLERGIC RHINITIS WHEN ALL FAILS
ADIL WARIS

2. SPONSOR MESSAGE
BAYER SPONSORED SESSION

3. Diagnosis Usually not difficult Symptoms can be seasonal or perineal
Allergic salute
Allergic crease
Look up nostrils at the inferior turbinates

4. Investigations Usually not needed Eosinophilia Serum IgE
Skin prick allergy test

5. Real six pack

6. TREATMENT 1 Antihistamines
For how long
Value of changing molecules
6 percent alcohol
Systemic delivery or local
For mild disease
For rhinorrhea
For sneezers

7. TREATMENT 2 Nasal steroids
Treatment of choice for blockers especially
Little side effects
Local application
Changing molecules
Different preservatives and propellents
Some with antihistamines
Onset of action 7 days and wears off in 7 days
Banov C, LaForce C, Lieberman P. Double blind trial of Astelin nasal spray in the treatment of vasomotor rhinitis. Ann Allergy Asthma Immunol 2000; 84:138.

8. TREATMENT 3 Saline douches
Washes out the cytokines
Do it before the steroid spray
Sea sprays
Saline sprays

9. TREATMENT 4 Montelukast
Systemic
Quick onset
Not all benefit
Useful is asthma is onboard

10. Cromolyn sodium nasal spray
1-2 sprays 3-4 times daily
No adverse effects
Cromolyn is less effective than glucocorticoid nasal sprays
Controlling mild symptoms.

12. Ipratropium bromide 0.03 percent nasal spray Decreasing rhinorrhea
Decreasing the release of substance P.
less effective than glucocorticoid nasal sprays
Useful in children or adults who have profuse rhinorrhea not otherwise controlled with topical nasal corticosteroids
Adult patients with concomitant allergic and nonallergic (or vasomotor) rhinitis. 

13. TREATMENT 5 Prevention Allergy testing House dust mite
Grass pollens especially Bermuda grass
Mould spores
Milk
Animal dander … remove pet all or nothing /hypoallergic animals
Other foods very unlikely

14. RESULTS Children aged 1 to 18 years 2005 to date 1150 patients results
Atopic asthmatics
Allergic rhinitis
Combinations of above

15. POLLENS Mould Mix 445 - 38.7% Bermuda Grass 251 - 21.8%
Grass Pollen Mix %
Tree Pollens Mix %
Weed Pollen Mix %
Pyrethrum %
Aspergillus %

16. LIVING CREATURES House dust mite 704 - 61.2% Cat 405 - 35.2%
Cockroach %
Dog %
Feathers %
Horse %
Rabbit %

17. FOODS Egg White 160 - 13.9% Milk 155 - 13.4% Soya 140 - 12.1%
Citrus Mix %
Egg Yolk %
Cereal mix %

18. NON ATOPIC STATE DEFINED
All negative %

20. Nasal decongestant sprays
Phenylephrine, oxymetazoline, xylometazoline, and naphazoline.
Downregulation of the alpha-adrenergic receptor develops after three to seven days,
Rebound nasal congestion may result.
Then viscious cycle --eventual dependency -- rhinitis medicamentosa. 

21. Chronic nonallergic rhinitis
 50 percent of patients with chronic rhinitis have a component of nonallergic rhinitis
Perennial symptoms and mild or absent nasal itching and sneezing.
Chronic nasal congestion and/or rhinorrhea changes in temperature and relative humidity, odors, or alcohol.
They have little nasal itching or sneezing.
Headaches, anosmia, and sinusitis are common.
Negative skin tests to inhalant allergens.
Include vasomotor rhinitis, gustatory rhinitis, and nonallergic rhinitis with nasal eosinophilia syndrome. 

22. Nasal hyperreactivity
Non IgE mediated
Biomass fuels
Oudh and incense
Smokers
Mossi chips and coils
Painting /varnishing
Scented candles

23. Nasal hyperreactivity
Karvol/ vicks /Echinacea
Humidifiers …mould counts
Vaporisers

24. Chronic rhinosinusitis
Inflammatory condition involving the paranasal sinuses and linings of the nasal passages
CRS can coexist with allergic rhinitis
Requires any two of the following symptoms, present for at least 12 weeks:
•Anterior and/or posterior mucopurulent drainage
•Nasal obstruction
•Facial pain, pressure, and/or fullness
•Decreased sense of smell

25. Rhinitis due to systemic medications
Birth control pills, antihypertensive drugs (alpha-adrenergic blockers, beta- adrenergic blockers, angiotensin-converting enzyme [ACE] inhibitors), erectile dysfunction drugs, and NSAIDs.
Psychiatric medications chlorpromazine, thioridazine, perphenazine, chlordiazepoxide, amitriptyline, and alprazolam.
cyclosporine and mycophenolic acid
Atrophic rhinitis – Atrophic rhinitis is a syndrome of progressive atrophy of the nasal mucosa usually seen in older adults. Such individuals report chronic nasal congestion and perceive a persistent bad odor. This condition is associated with mucosal colonization with Klebsiella ozaenae. A variant occurs in patients who have had multiple sinus surgeries resulting in loss of normal mucociliary function. This is discussed separately. (See "Atrophic rhinosinusitis".)
●Rhinitis associated with hormonal changes – Rhinitis of pregnancy and rhinitis of hypothyroidism reflect nasal obstruction that occurs on a hormonal basis. In these settings, the diagnosis is clinical and is supported by negative skin tests or improved symptoms upon resolution or treatment of the causative condition. (See "Clinical manifestations of hypothyroidism" and "Maternal adaptations to pregnancy: Physiologic respiratory changes and dyspnea", section on 'Respiratory changes'.)
●Unilateral rhinitis or nasal polyps – Unilateral rhinitis or nasal polyps are uncommon in uncomplicated allergic rhinitis. Unilateral rhinitis suggests the possibility of nasal obstruction by a foreign body, tumor, or polyp, and the presence of nasal polyps suggests nonallergic rhinitis with eosinophilia syndrome (NARES), chronic bacterial sinusitis, allergic fungal sinusitis, aspirin hypersensitivity, cystic fibrosis, or primary ciliary dyskinesia (immotile cilia syndrome). Fiberoptic rhinoscopy may be helpful in this setting. Increasing evidence also suggests that the histology of those with rhinitis with or without nasal polyps are different, with eosinophils or neutrophils predominating in those with or without polyps, respectively [91]. However, allergic rhinosinusitis and NARES are both conditions characterized by nasal eosinophilia, but most patients with these conditions lack nasal polyps. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Fungal rhinosinusitis" and "Epidemiology and clinical manifestations of invasive aspergillosis" and "Cystic fibrosis: Clinical manifestations and diagnosis".)
●Rhinitis with immunologic disorders – A number of systemic autoimmune disorders present with nasal symptoms or can affect nasal mucosa. These include granulomatosis with polyangiitis (Wegener's) and relapsing polychondritis:
•The most common presenting symptoms of granulomatosis with polyangiitis include persistent rhinorrhea, purulent/bloody nasal discharge, oral and/or nasal ulcers, polyarthralgias, myalgias, or sinus pain.
•With relapsing polychondritis, symptoms of stuffiness, crusting, rhinorrhea, and on occasion, epistaxis, may accompany nasal cartilage inflammation, which can also compromise olfaction. Cartilage destruction associated with sustained or recurrent episodes of inflammation can result in a characteristic saddle-nose deformity.
Such disorders may therefore present with nasal symptoms, without evidence of systemic disease. These disorders are diagnosed based upon the combination of characteristic histologic and clinical findings. (See "Granulomatosis with polyangiitis and microscopic polyangiitis: Clinical manifestations and diagnosis" and "Clinical manifestations of relapsing polychondritis".)

26. Alternative therapies
Traditional Chinese medicine (TCM) includes herbal therapy, acupuncture, massage, and dietary therapy.
Studies of acupuncture for the treatment of allergic rhinitis have shown modest benefit
There are several herbal therapies that have demonstrated efficacy, including Ayurvedic mixes, butterbur, and Tinospora cordifolia.
Nasal sprays consisting of dilute solutions of capsaicin have shown efficacy for allergic rhinitis in randomized trials when administered several times daily.
National Center for Complementary and Alternative Medicine. Expanding Horizons of Health Care: Strategic Plan NIH publication no , National Center for Complementary and Alternative Medicine; NIH, Bethesda, MD 2005.

27. Allergic rhinitis under in infancy
Does it exist
Airway sensitization
Role of milk allergy via breast milk
Ng ML, Warlow RS, Chrishanthan N, et al. Preliminary criteria for the definition of allergic rhinitis: a systematic evaluation of clinical parameters in a disease cohort (I). Clin Exp Allergy 2000; 30:1314.

28. NEVER FORGET Are the patients adherent
Is the inhaler technique for the nose spray correct
Douche first then steroid spray
Have you treated asthma?

29. Kenya future
Allergen immunotherapy … takes long and do you have the correct ingredients