1. Allergic Rhinitis Dr. Shishir Modak Past President – IAP Pune
Master trainer in ATM , RTI – GEM, PSPID
RAP , Nutrition , TB Modules

2. Allergic Rhinitis Case 1 Varshini 11 yr old girl
H/o Recurrent cold since 6 months. Paroxysmal sneezing , Sneezing more than 50 times in few minutes.
Symptoms worsen in August/ September
? Seasonal Allergic Rhinitis , ? Viral

3. Allergic Rhinitis Case 2 Shourya 5 yr old boy
H/ o Cough , cold off & on for last 3 months. H/ o Fever & Earache 2 months back . Subsided with a course of antibiotic.
However Cold & Cough Don’t go away. It is always there. No Breathlessness.
Could it be Allergic ?

4. Allergic Rhinitis Salil, 5 yr old boy Cough, Cold , Sneezing - 15 days
Case 3
Salil, 5 yr old boy
Cough, Cold , Sneezing - 15 days
No Fever , No chest signs
Recurrent since 4 months. GP gave Antibiotic , Nebulization & Cough Syrup but cough, cold persists. Now he has started Aerocort inhaler since 5 days & patient has come for a second opinion.

5. Allergic Rhinitis
Patients come to us with common symptoms of Recurrent Cough & Cold with few additional points which are different in each patient.
These confusing symptoms should be dissected out & Analyzed.
Careful History & Examination is a must.

6. Allergic Rhinitis Need to differentiate between
Allergic Rhinitis & Infectious Rhinitis (Cold) Sinusitis – Allergic/ Viral/ Bacterial
Adenoid Hyperplasia & Otitis Media –
? Infectious with ? Underlying allergy
Allergic Rhinitis alone Or As a Co morbid with Asthma
Tratment Plan changes accordingly.

7. Allergic Rhinitis Symptoms suggestive of AR
2 or more of the following symptoms for >1 hr on most days
Watery Rhinorrhea
Sneezing, esp. paroxysmal
Nasal Itching
Nasal Obstruction

8. Allergic Rhinitis Symptoms usually NOT associated with AR
Unilateral symptoms ++++
Only Nasal obstruction
Mucopurulent Rhinorrhea-Posterior Rhinorrhea (post nasal drip)-With thick mucus-& no anterior Rhinorrhea-
Pain, Recurrent Epistaxis & Anosmia
Refer patient to an ENT

9. Allergic Rhinitis Common Cold Allergic Rhinitis
Cold lasts for a week Cold lasts > 10 days
Usually Fever Fever absent
Constitutional sympt Allergic Signs
Nasal mucosa Red Nasal mucosa pale
?Response to Antihist Good response to Antihist
Family members affected Not affected at a time

10. Allergic Rhinitis Symptom Clues beyond nose Ocular Allergy –
Watering , Itching & Redness of eyes
( Allergic Conjunctivitis )
Eczemas – Atopic Dermatitis
Ear Fullnss
Palatal Pruritus

11. Allergic Rhinitis Symptomps of Co morbidities & Complications
Sinusitis – Headache , Bad Breath, Cough in Lying down posn.
OSA – Snoring , Mouth Breathing, Hyper Nasality of Voice
Otitis Media with Effusion ( OME )
Asthma – Uncontrolled Asthma

12. Allergic Rhinitis 4 major cardinal symptoms of AR are –Sneezing
–Itching (Nasal)
–Rhinorrhoea
–Congestion
Allergic Rhinitis (AR) is a chronic inflammatory disease of the nose induced by an IgE mediated inflammation, after allergen exposure of mucus membrane of nose
Children affected with AR – 5 – 25 %

14. Allergic Rhinitis History Ask for
Running Nose – Clear Watery Discharge
Paroxysmal Sneezing
Nasal itching
Associated Nasal Block
Watering of Eyes, Itching, redness
Atopic Eczemas, Asthma like Symptoms
Family H/o Allergy

15. Allergic Rhinitis Examination Allergic Signs –
Allergic Shiners – Dark Circles below eyes
Allergic Salute – Rubbing nose in upward direction
Darrier Line – Horizontal crease above tip of the nose
Allergic Gape – Mouth Breathing , Snoring

16. Allergic Rhinitis
Itching of Nose with Rhinorrhea

17. Allergic Rhinitis
Allergic Shiners

18. Allergic Rhinitis
Transverse Crease

19. Allergic Rhinitis
Allergic Salute

20. Allergic Rhinitis Grouping of Nasal Symptoms Sneezers & Runners
Paroxysmal Sneezing, Watery Ant. Rhinorrhea, Nasal itching , conjunctivitis,
Worse during day , Improves at night
Blockers –
Little Sneezing, Thick mucus, Severe congestion, worse at night

22. Management of Allergic Rhinitis
Drugs
Stepwise Approach
Mild Intermittant
Second Generation H1 Antihistaminics
Or LTRA

24. Management of Allergic Rhinitis
Mild Persistent
Second Generation H1 Antihistamines + LTRA + INS
Allergen Avoidance
Severe Persistent
SGH1A + LTRA + INS
Allergen Specific Immunotherapy

25. Allergic Rhinitis Oral H1 Antihistamines First Generation –
CPM , Diphenhydramine, Promethazine, Triprolidine
Drying of Secretions , Drowsiness ,
Anti Cholinergic Side Effects
Cognitive impairment
Should not be used

26. Allergic Rhinitis Second Generation Antihistaminics – Preferred Drugs
No or little drowsiness, Minimal side effects, Safe for long term use.
Cetrizine , Levocetrizine
Fexofenadine
Loratadine

27. Allergic Rhinitis Topical Antihistaminics Delivered by Nasal Spray
Quick action in minutes.
Side Effects – Bitter taste, some irritation, Drowsiness. Can be used above 5 yrs.
Azelastine spray – 1 – 2 sprays o.d.

28. Allergic Rhinitis Montelukast LTRA
Recommended for all severities of AR.
Useful for AR with Asthma
Safe for long term use
Dose 4mg upto – 5 yrs
5 mg – 5 to 10 yrs
10 mg – above 10 yrs
Fixed dose combi with H1 Antihist.= avoid

29. Allergic Rhinitis Intra Nasal Steroids
First line therapy for moderate-severe AR
Effective against all symptoms of AR incl. Congestion, Sneezing, Itching (nasal), Rhinorrhea, & Eye symptoms
Most efficacious medication available for Allergic Rhinitis

30. Allergic Rhinitis Intra Nasal Steroids
Onset of action hours of dosing
Up to 2 weeks required for optimum effect
Very useful for nasal blockers
Quality of life score improvement with INSs better than oral & topical H1 antihistamines

31. Allergic Rhinitis Intra Nasal Steroids
Choose INS with low systemic bio availability
Mometasone Furoate,
Fluticasone Furoate
Fluticasone Propionate
Avoid – Beclomethasone, Triamcinolone
Negligible side effects even after long term use
Compliance & Technique should be checked

32. Allergic Rhinitis Intra Nasal Steroids Technique –
Clear the nose of the secretions
Insert the nozzle into the nostril
Direct the spray laterally away from the septum - towards the ear
Use right hand to spray left nostril & left hand to spray right nostril

34. Allergic Rhinitis Intra Nasal Decongestants
Xylometazoline, Oxymetazoline
Effective in nasal obstruction.
To be used only for short term = 5 – 7 days
Do not improve nasal itching, rhinorrhea & sneezing
Prolonged use results in Tachyphylaxis & rebound congestion
Oral Decongestants – Not Recommended
Phenylephrine, Pseudoephedrine,

35. Allergic Rhinitis Environmental Control Triggers –
Outdoor – Allergens -Pollens – Tree, Grass, Weeds
Indoor – House Dust Mite, Fungal Molds, Pets, Cockroaches
Irritants – Cigarette Smoke, Mosquito Coil,
Cooking fuels, Air Pollution
Avoidance of Environmental Triggers important

36. Allergic Rhinitis ImmunoTherapy Indications
Moderate / Severe Persistent AR
Inadequate response to Pharmacotherapy
Unsatisfactory Compliance
Inadequate response to Environmental Control
Specific 2- 3 Allergens

37. Allergic Rhinitis ImmunoTherapy - Called as ‘Allergy Vaccines’
Modifies underlying cause of Allergy
Short term & long term benefits
Sustained effect even after treatment withdrawal
Useful in Allergic Rhinitis & Asthma
Allergy Skin Test a Prerequizite

38. Allergic Rhinitis Subcutaneous Immunotherapy
Very Effective , Side effects – Urticarias, Severe Systemic Reactions , Clinic visits reqd.
Sublingual Immunotherapy -
Effective, Less side effects, Systemic reactions rare, Can be given at home.

39. Allergic Rhinitis AR & its impact on Asthma
30% of AR patients have Asthma,
80% asthmatics have AR
AR is a risk factor for Asthma
AR & Asthma share common allergens
Proper treatment of AR improves Asthma Control & PFT

40. Allergic Rhinitis Take Home Messages
Look for Cardinal Symptoms – Rhinorrhea, Itching, Sneezing,Nasal Block
Watch for CoMorbids – Asthma, Occular Allergy, Adenoid Hypertrophy
Rule out or treat Infections
SGH1A, LTRA, INS depending on severity
Treatment of AR improves Asthma control.
Specific Immunothrapy in rare cases

41. Allergic Rhinitis
THANK YOU !