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Rhinitis

Allergic or Nonallergic Rhinitis?


Taking the Questions Out of
Diagnosis and Treatment

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Acknowledgments
This is a presentation of the
American Academy of Family Physicians
supported by an educational grant from
Aventis Pharmaceuticals
The AAFP gratefully acknowledges
Harold H. Hedges, III, M.D.
and
Susan M. Pollart, M.D.
for developing the content for the AAFP
and
Harold H. Hedges, III, M.D. and Lincoln Diagnostics for providing the photo
images included
in this slide presentation.

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Acknowledgments
Harold H. Hedges, III, M.D.
Private Practice
Little Rock Family Practice Clinic
Little Rock, Arkansas

and
Susan P. Pollart, M.D.
Associate Professor of Family Medicine
University of Virginia Health System
Charlottesville, Virginia

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Upon Completion of This Presentation


You Should be Able To:
Distinguish allergic, nonallergic and mixed rhinitis from other upper
respiratory diseases
Identify each entity utilizing history, physical exam, appropriate lab
tests, and allergy screening utilizing either skin prick test or in vitro
testing
Define the pathophysiology of allergic rhinitis
Identify environmental allergens common to the geographic area as
well as triggers found in the home and work place
Identify pharmacologic and nonpharmacologic treatment options for
managing allergic and nonallergic rhinitis
Recognize when further allergy testing or referral to an allergist
might be indicated

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Evidence-based Rhinitis Care


Most guidelines/algorithms presented for treatment of
rhinitis are based on expert opinion, not strong evidence
Experience from experts practices may not apply to a
family care setting
Emphasize what treatments have evidence-based support
and be knowledgeable about optional treatments

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Evidence-Based Recommendations
Practice Recommendation: Treat patients diagnosed as having allergic seasonal rhinitis
with prophylactic medications (antihistamines and/or intranasal corticosteroids).
Practice Recommendation: Prescribe intranasal corticosteroids to control allergic
rhinitis symptoms.
Practice Recommendation: Educate patients with allergic rhinitis about avoidance
activities.
Practice Recommendation: Reserve immunotherapy for patients with allergic rhinitis
for whom optimal avoidance measures and medication therapy are insufficient to
control symptoms.
All recommendations available at: http://www.icsi.org/knowledge/detail.asp?
catID=29&itemID=158.
Accessed August 2003.

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Epidemiology and Prevalence

Epidemiology Of Rhinitis
Affects 100% of the population
Often self-limited and associated with viral URI
With chronic symptoms, determining etiology guides
therapy
Major separation is between allergic, nonallergic and
mixed rhinitis

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Epidemiology Of Rhinitis
Allergic rhinitis was reported the second most prevalent
chronic condition in the United States in 1994
Affects 40 to 50 million people
Incidence highest in people ages 15-25 years
Estimates of nonallergic rhinitis lacking
In one study, 57% of patients with chronic rhinitis had
nonallergic or mixed rhinitis

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Allergic Rhinitis
50% patients symptomatic > 4 months/year
20% patients symptomatic > 9 months/year
10,000 children out of school daily
10,000,000 office visits annually
2,000,000 days of missed school
And this accounts only for allergic rhinitis, nonallergic rhinitis is
another issue

Blais, MS. Costs of allergic rhinitis in Current Views of Rhinitis

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Daily Costs of Rhinitis


Second generation antihistamines $2 to 2.50/d
Steroid nasal sprays $1.40 to 1.90/d
Decreased cost of lost production?
Cost associated with absenteeism?
Cost associated with associated diseases?

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prod
uctio
ism n
e
e
nt
e
s
abdiseases

Impact of Allergic Rhinitis


$5.3 billion for direct and indirect costs in year 1996
Affects 10% to 30% of adults, 40% of children
Results in more than 2 million lost school days/year

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Allergic or Nonallergic?
A dilemma for family care physicians
Allergic? Nonallergic? Mixed?
Can we distinguish rapidly in the course
of a busy day?
Is there a quick, cost-effective test?

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Approach to Dx and Rx
Hypertension, diabetes, infections
Hx/Px>>>>Lab>>>>Dx>>>>Rx

Rhinitis
Hx/Px>>>>Dx>>>>Rx
Dx may be wrong up to half of the time

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Classification of Rhinitis
Allergic Rhinitis
Seasonal allergic rhinitis (SAR)
Perennial allergic rhinitis (PAR)

Nonallergic Rhinitis
Infectious
Idiopathic or vasomotor
Drug-induced
Rhinitis medicamentosa

Hormonal
Anatomical
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Types of Rhinitis
Pure allergic rhinitis

43%

Pure nonallergic rhinitis

23%

Mixed

34%
100%

57% Non allergic component

National Allergy Advisory Council meeting, The broad spectrum of rhinitis: etiology,
diagnosis, and advances in treatment. St. Thomas, US Virgin Islands; 1999.
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Annals of Allergy, Asthma, and Immunology


Vol 2., May 1999
Every physician seeing a suspected allergic patient should
consider testing for allergen-specific IgE to
identify the specific cause.
Addresses the difficulty of differentiating the types of rhinitis
on the basis of history and physical alone

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Why Bother Defining Rhinitis?


Provides evidence leading to medication selection
Reduces cost of inappropriate medications
Overall, patients have a better understanding of their
disease when their physician can explain specifically

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Defining the Types of Rhinitis


Helps in discussing expectations of medication or other
treatment
Helps explain why some allergic patients do not fully respond to
antihistamines (nonallergic component does not respond to
antihistamines)
Helps explain why some allergic patients on immunotherapy do
not totally respond to treatment (the nonallergic component has
not been addressed)

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Quality-of-Life Issues
Fatigue

Missing school/work

Concentration

Halitosis

Nuisance

Decreased daily
production

Sleep disturbance
Emotional well being
Social interactions

Impaired studying
Sniffing/snorting
Blowing nose

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Quality of Life in Seasonal Allergic Rhinitis


Overall RQLQ
Fexofenadine 120 mg qd is significantly better than loratadine
in improving quality of life with respect to SAR symptoms

Change from baseline


(mean)

0.0

-0.4

-0.8
Lor vs placebo: NS
Fex vs placebo: P <0.005
Fex vs Lor: P 0.03

-1.2

-1.6
Fex 120 mg qd
Placebo
Lor 10 mg qd
Baseline score ~ 3.0
van Cauwenberge, et al. Clin Exp Allergy: 2000;30:891.

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Pathophysiology
Direct effects of histamine
Indirect effects of histamine
Other mediators of the immune response

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Effects of Histamine in the Allergic Reaction


Direct:
Histamine receptors: activation
Mast cells and basophils: destabilization
Endothelial cells: increase expression of adhesion
molecules
Epithelial cells: increase expression and production of
cytokines, chemokines and adhesion molecules
Macrophages: increase IL-6 production
T-cells: increase cytokine production
Adcock. Clin Exp Allergy Rev. 2002;2:85-88.
Bousquet J. et al. J Allergy Clin Immunol. 2001;108:S147-S333.
Marone et al. Int Arch Allergy Immunol. 2001;124:249-52.
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Effects of Histamine in the Allergic Reaction


Indirect:
Eosinophils: increase maturation and migration, and
promotion of apoptosis
IL-5, GM-CSF, RANTES, eotaxin, adhesion molecules

Neutrophil: increase migration and adhesion


IL-8, leukotrienes, adhesion molecules

IgE: increase production


IL-4, IL-13
Adcock. Clin Exp Allergy Rev. 2002;2:85-88
Bousquet J. et al. J Allergy Clin Immunol. 2001;108:S147-S333
Marshall GD. JACI. 2000;106:S303-309
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Other Mediators of the Allergic Reaction


Mast cells also influence AR through release of other
proteins, metabolites, and cytokines
Degranulation releases proteins (e.g., tryptase and chymase) and
proteoglycans (including heparin and chondroitin sulfate)
Arachidonic acid metabolites (including leukotrienes and
prostaglandins) synthesized de novo following cell activation

Variety of preformed cytokines released

Occurs more rapidly than from activated T-cells


Antihistamines inhibit antigen-induced release of histamine and
other mediators from mast cells and basophils in vitro

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Bousquet J. et al. J Allergy Clin Immunol. 2001;108:S147-S333


De Paulis A. et al. (Abstract). Allergy. 1999;54 (suppl 52):278
Lindstedt KA. et al. J Lipid Res. 1992;33:65-75
Marshall GD. JACI. 2000;106:S303-309

Early Response
Leakage of blood vessels
Mucosal edema
Rhinorrhea
Secretion of mucoglycoconjugates
Congestion
Nasal itching
Sneezing

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Managing Patients with Allergic Rhinitis


Four general principles of allergy management
1. Education and monitoring
2. Avoidance of trigger factors
3. Pharmacotherapy
4. Immunotherapy

The Allergy Report. Am Acad Allergy Asthma Immunol. 2000.


Dykewicz M, et al. Ann Allergy Asthma Immunol. 1998;81:478-518.
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Case Study
Patient presents with runny nose, nasal congestion, constantly
clearing his throat, sniffing, snorting, disruptive to fellow
students. Requests a prescription for an antihistamine like the
one I saw on TV.
What else do you need to know before prescribing medication?
What physical signs can help you?
What quick, in-office tests can help you with a diagnosis?

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What Do You Need to Know in Addition


to Symptoms?
Age at onset
Are sx acute, chronic, recurrent, seasonal or perennial?
What causes the symptoms?
What is the response to antihistamines?
Does patient have any pets (cats, dogs, animals with hair)?
Any associated illnesses (asthma, skin rash, otitis media)?
Is there a family history of allergy?

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Allergic Patients Generally Have


Early onset of symptoms (70% < age 20)
Family history of allergy
Seasonal symptoms
Symptoms with animal exposure
Symptoms worse outdoors
Symptoms worse near fresh-cut grass
Symptoms better in air conditioning
Tobacco and chemicals are not primary excitants
Previous immunotherapy was helpful

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Bimodal Occurrence of Allergic Rhinitis


First appears in elementary school ages
Abates during middle and high school ages
Reappears in 20s and 30s

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Nonallergic Patients Generally Have


Later onset of symptoms (70% > age of 20)
No family history of allergy
Tobacco smoke and chemicals primary excitants
Weather changes provoke symptoms
No seasonal aspect to symptoms
No symptoms with exposure to dust
No symptoms with exposure to animals

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Risk Factors for Rhinitis


Asthma, atopic dermatitis, allergy
Family history of allergy
Daycare centers
Viral infections
Occupational exposures
Hobbies, weekend activities
Flying

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Causes of Rhinitis

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Allergy

Irritants

NARES syndrome

Adverse food reaction

Occupational

Emotional

Hormonal

Atrophic

Drug induced

Ciliary dyskinesia

Anatomic defects

Immunodeficiency
diseases

Allergic Rhinitis

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Rhinitis Case Study


8-year-old female with year-round sneezing, nasal
congestion, worse in spring and fall, recurrent otitis media,
occasional wheezing with URIs, misses 20 plus days of
school per year, sniffling, throat clearing. Lethargic, tired
all the time. Father is allergic. Not doing well in school.
This is her 4th office visit this year.
Afebrile. Allergic shiners. Nasal discharge. Nasal crease.
Bluish tint to congested nasal mucosa. Lungs are clear.

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Diagnosis: Typical Patient with Allergic


Rhinitis with its Common Morbidities
Perennial allergic rhinitis with seasonal exacerbations
Recurrent otitis media
Asthma triggered by viral infections

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Symptoms of Allergic Rhinitis


Sneezing
Nasal congestion
Watery nasal discharge
Itchy watery eyes
Postnasal drip
Itching

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Physical Changes of Allergic Rhinitis


Pale blue, edematous turbinates
Clear, watery nasal discharge
Crease from nasal salute
Lymphoid hyperplasia
Watery, itchy eyes

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Photo Image of Nasal Salute

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Allergic Rhinitis and Concomitant Disease


Management of allergic rhinitis may decrease
exacerbations of sinusitis, asthma and otitis media
Early immunotherapy for allergic rhinitis has been shown
to decrease the development of asthma

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Evaluation of Rhinitis
History and physical
Sinus transillumination
Direct visualization with nasal specula
Rhinoscopy
Nasal smear
Allergy screening tests (skin tests or RAST)
Imaging for persistent disease

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Allergy
History Screen

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Physical Exam-NARES
External appearance, evidence of trauma
Color, consistency of nasal discharge
Mucosal swelling
Presence of odor
Polyps, septal deviation, concha bullosa
Tenderness over sinuses

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Physical Examination
Eyes: conjunctivitis, dark circles, Dennies lines
Ears: OM, TM mobility, serous otitis
Mouth: mouth breathing
Lungs: wheezing

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Nasal Smear
Clear nose of secretions
Gently scrape sample from mucosa of inferior or middle
turbinate with plastic ear spatula or cotton swab
Wrights or Hansels stain
Eosinophilia
Allergy (present in 90% of allergic patients)
NARES syndrome
Aspirin sensitivity

Neutrophilia
Infection

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Sinus X-rays and CT Scans Only for


Chronic or Recurrent Disease

Sinus x-rays (cost $353: local hospital)


Not needed for diagnosis of acute rhinosinusitis
Waters view for the maxillary sinuses
Towns view for ethmoid and frontal sinuses
Lateral view for the sphenoid

Limited coronal CT scan (cost $397: local hospital)


Osteomeatal complex
All sinuses visualized

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CT scan gives much better imaging for minimal increased cost

Photo Image of Rhinoscope

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Rhinoscopy
Nasal polyps
Septal deviation
Concha bullosa
Eustachian tube dysfunction
Causes of hoarseness
Adenoid tissue
Tumors

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Treatment of Allergic Rhinitis


Avoidance of identified allergens
Nasal steroids
Antihistamine nasal spray
Antihistamines (sedating and nonsedating)
Decongestants
Nasal sprays (limited 2-3 days)
Oral preferred (limited by side effects)

Nasal irrigation
Leukotrienes

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General Treatment Modalities


Vigorous exercise
Posture
Avoidance procedures
Saline irrigation

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Nasal Irrigation
Commercial buffered sprays
Bulb syringe
1/4 tsp of salt to 7 ounces water
Waterpik with lavage tip
1 tsp salt to reservoir
Disposable enema bucket
2 tsp salt, 1 tsp soda per quart of water

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Nasal Irrigation
Washes away irritants
Moistens the dry nose
Waterpik with nasal irrigator
Ceramic irrigators
Enema bucket with normal saline and soda
hose-in-the-nose-- $2.50

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Treatment of Mild Allergic Rhinitis


Occasional exposure/symptoms
Environmental control
Saline irrigation
Monotherapy
Nasal steroid or
Nonsedating antihistamine or
Astelazine nasal spray

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Step 1

Treatment of Moderate Allergic Rhinitis Sx


May Last for Months to One Year Step 2
Environmental control
Normal saline irrigation
Combination therapy
Nasal steroid and
Nonsedating antihistamine with or without decongestant or
Astelazine

Immunotherapy

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Treatment of Severe Allergic Rhinitis


Chronic, persistent associated with Sinusitis, Otitis media and asthma

step 3
Environmental control
Normal saline irrigation
NSA+/- decongestant
High-dose nasal steroid
Afrin 3 days or fewer
Oral steroid
Immunotherapy

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Environmental Control/Avoidance
Dust mites
Controls: plastic covers, frequent vacuuming of carpet
Avoid: overstuffed chairs, curtains, stuffed animals, dust-collecting
boxes under bed
Cockroaches
Poisoning

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Environmental Control
Air conditioning
Frequent dusting, cleaning surfaces
Air filters
Hepa filtration
Vacuum cleaners
Dry versus water filtration
Ionizers
Wood burning stoves

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Environmental Control Animals

Cats and dogs


Unrealistic:
Get rid of or give away
Realistic:
At least out of the house
Dogs usually will become yard dogs
Cats will stay in the house
Out of the bedroom
Washing cats 1-2 times weekly

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Environmental Control of Molds


Remove sources of mold growth
Piles of leaves, clothes, foods
Control humidity
Basements, closets, bathroom areas
Increase ventilation
Remove under-house water
Fungicides
Clean humidifiers, vaporizers

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Pharmacotherapy

Allergic rhinitis
Antihistamines
OTC
Nonsedating

Nonallergic rhinitis
Antihistamines
Drying effect

Decongestants

Nasal steroids

Astelazine

Nasal cromolyn

Ipatropium

Astelazine nasal spray

Nasal steroids

Decongestants

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NARES syndrome

Nasal Steroids
Flonase
Beconase
Nasonex
Nasacort
Rhinocort
Vancenase
Tri-Nasal

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Nonsteroid Nasal Sprays


Astelazine
Atrovent
Nasalcrom
Saline

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Comparison of Various Approaches


to the Treatment of Allergic Rhinitis
Antihistamines
traditional (A)
Nonsedating
(NSA)
Azelastine
Decongestants
NSA +
decongestants
Leukotriene antag.*
Cromolyn
Nasal CCS (NCS)
NSA + NCS
Immunotherapy

Sneezing

Discharge

Itch

Congestion

Side effects

+++

+++

+++

+++

+++
+++

++
++
+

+++
+++

+
+
+++

to +
to +
++

+++
+ to ++
++
+++
++++
+++

+++
+ to ++
+
+++
++++
+++

+++
+ to ++
+
+++
++++
+++

+++
++
+
+++
++++
+++

++
to +

+
+
+ to ++

* = Presumed; no data on individual symptoms Nayak AS, et al. Ann Allergy Asthma Immunol.
2002;88:592-600. ++++ = Strongly positive effect; + = Minimal effect
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Nonallergic Rhinitis
As important as allergic rhinitis
Present in 57% of patients with rhinitis

66

Nonallergic/Vasomotor Rhinitis
Perennial or episodic symptoms
Chronic, nonpruritic rhinorrhea/congestion
Negative nasal eosinophils
Negative allergy screening
Nonallergic excitants

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Viruses
Chemicals, tobacco smoke, potpourri
Nonallergic foods
Weather changes

Symptoms of Nonallergic Rhinitis


Nasal congestion is prominent
Sneezing and nasal itching uncommon
Concomitant asthma is less likely
Eye symptoms are fewer
Postnasal drip
Fatigue
Loss of sense of smell and taste

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Tests Helpful in Diagnosing


Nonallergic Rhinitis
Nasal smear will be void of eosinophils
Eosinophils present in 90% of allergic rhinitis
Neutrophils suggest bacterial infection

Skin prick tests or in-vitro testing negative


Negative allergy testing is the best predictor of the
nonallergic state

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Treatment of Nonallergic Rhinitis

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Astelazine nasal spray


Steroid nasal spray
Nasal irrigation
Avoidance
Effectiveness of antihistamines questionable

Rhinitis Case Study


23-year-old has had nasal congestion for the past 23
months. Started as a cold, but symptoms never cleared.
Allergies several times a year as a child but outgrew
them. Never tested. No family hx of allergy. Cant sleep
without his medication.
Is he allergic?
What is your next question?

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Rhinitis Case Study


What medication are you using?
Answer: Afrin, I cant breath or sleep without it.

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Rhinitis Medicamentosa
Rebound congestion from overuse of topical
decongestants; oxymetazolone, phenylephrine, cocaine
Erythematous mucosa, congestion, punctate bleeding
Interstitial edema and vasoconstriction
Withdrawal of medication, topical steroids, oral steroids

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Treatment of Rhinitis Medicamentosa


Initiate topical steroid bilaterally, discontinue decongestant
in one nostril, then the second nostril one week later
One-week dose of tapering steroids
Evaluate for the underlying cause of the rhinitis

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Medications That May Cause Rhinitis

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Aldomet

Minipres

Cardura

Moduretic

Catapres

Normodyne

Corgard

Trandate

Hytrin

Viagra

Ismelin

Wytensin

Hormonal Causes of Rhinitis


Pregnancy
Second month to term

Puberty
Oral contraceptives
Hypothyroid state

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Rhinitis of Pregnancy
Mild symptoms may have been present before (pregnancy
aggravated symptoms)
Increase in circulating blood volume
Progesterone induced smooth muscle relaxation
Hormonal effect on nasal mucosa

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Treatment of Rhinitis in Pregnancy


Caution with medication usage
Nasal saline sprays, steam inhalation
Avoidance of known triggers
Topical medical therapy rather than systemic when
possible
Oral pseudoephedrine
Chlorpheniramine

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Rhinitis Case Study


28-year-old with a two-year history of profuse rhinorrhea.
No history of rhinitis or asthma as child. Occasional
sneezing, little congestion.
Clear nasal discharge on exam, pharynx, tympanic
membrane, lungs all normal.
Skin test is negative with good positive control.
What in-office test will make the diagnosis clear?

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NARES Syndrome
Nasal smear revealed marked eosinophilia
Diagnosis: NARES syndrome nonallergic rhinitis with
eosinophilia

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NARES Syndrome
Perennial symptoms
Sneezing
Rhinorrhea
Pruritis

Occasional loss of smell


Nasal smear positive for eosinophils
Allergy screen is negative

001903

Nasal Mastocytosis is Rare


Basophilic metachromic nasal disease
Histologic diagnosis
Mast cell infiltration of the mucosa
No eosinophils

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Rhinitis Case Study


2 year-old male presents with purulent, foul smelling
rhinorrhea, pain on pressure about the left side of nose. No
sneezing, is congested.
Temp 99.2, irritable, crying, hard to examine. Left TM
red. Lungs clear. Nose is congested, purulent rhinorrhea,
more on left than right. Fights you trying to examine his
nose and throat.

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Diagnosis?

Acute Bacterial Rhinitis Secondary to


Foreign Body
Unilateral purulent rhinorrhea
Localized pain
Leucocytes on nasal smear
Erythema and swelling of the area involved
Distortion of the nose from swelling
Odor

001903

Atrophic Rhinitis (Ozena)


Found in patients who have had radical nasal tissue
removal for congestion
Removal of inferior and or middle turbinates
Empty nose syndrome

Excessive drying, crusting and infection


Atrophic changes in the elderly
Klebsiella colonization

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Treatment of Atrophic Rhinitis


Nasal irrigation 3-4 times per day for 2-3 months, then 1-2
times per day indefinitely

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Rhinitis Case Study


45-year-old female with no history of previous symptoms
of rhinosinusitis presents with headaches, daily nasal
congestion and fatigue for 3-4 months. No hx of viral URI.
No family hx of allergy. No changes in cosmetics, no
additions to house, no new clothes. No pets. No food
reactions known.
What other element of a thorough history might give you a
clue as to diagnosis?

001903

Rhinitis Case Study


Where do you work?
How long have you worked there?
Do your symptoms coincide with changing jobs?
Are you more symptomatic at work than at home?
Do your symptoms clear on the weekend or on vacation?

001903

Occupational Rhinitis
Patients experience symptoms in workplace
Symptoms improve on weekends/vacation
May be allergic or nonallergic
May coexist with occupational asthma
Treatment is avoidance
Move to another area in the workplace
Move to another job

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Causes of Occupational Rhinitis


Sick building syndrome
Department of Ecology and Environmental Protection

Gasses from office machines


Inks, paper

Perfumes
Paints, carpet, carpet glue
Laboratory animals

001903

Common Workplaces for


Occupational Rhinitis

001903

Beauty salons

Tanneries

Clothing stores

Paper industry

Supermarkets

Gardening products

Auto body spraying

Insecticides

Service stations

Food industry

Woodworking

Laboratory animals

Pesticide industry

Office machinery

Plastic manufacturing

Paints, chemicals

Common Chemical Exposures


Causing Rhinitis

001903

Gasoline/diesel fuels
Chlorine
Perfumes
Cleaning agents
Room deodorizers
Hair dyes
Permanent solutions
Paints
Auto body paints
Herbicides

Potpourri
Burning candles
Petroleum products
Formaldehyde
New clothing odor
Hair spray
Toluene
Ammonia
Acids

Mechanical Causes of Rhinitis


Deviated nasal septum

Meningocoele

Nasal polyps

Adenoid hypertrophy

Foreign body

Variants of the osteomeatal


complex

Tumors of the nose


Congenital atresia

001903

Concha bullosa

Gustatory Rhinitis
Rhinorrhea and/or nasal congestion related to eating
Treatment is identification and elimination
Common causes of gustatory rhinitis
Wines
Cheeses
Spicy foods

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Food Reactions
Diagnosed by skin prick tests, RAST or elimination diet
Skin prick tests, in-vitro testing will only diagnose
IgE-related foods
Elimination diet will diagnose all types adverse food reactions

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Vasculitides, Autoimmune and


Granulomatous Causes
Churg-Strauss Syndrome vasculitis
Systemic lupus erythematosis
Relapsing polychondritis
Sjogrens syndrome
Sarcoidosis
Wegeners granulomatosis

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Pharmacotherapy
Allergic rhinitis
Antihistamines
OTC
Nonsedating

Antihistamines
Drying effect

Decongestants

Nasal steroids

Astelazine

Nasal cromolyn

Ipatropium

Astelazine nasal spray

Nasal steroids

Decongestants

001903

Nonallergic rhinitis

NARES syndrome

Treatment of Bacterial Rhinitis


Antibiotics
Ointment
Systemic

Saline sprays

001903

Treatment of Atrophic Rhinitis


Saline irrigation
Ipatropium

001903

Nasal Polyps
Grape-like clusters
Maxillary sinus

Inflammatory process
One third associated with asthma
Asthma-aspirin-polyp triad

High rate of recurrence

001903

Nasal Polyps
Allergy control
Intranasal steroids
Systemic steroids
Avoidance of ASA, NSAIDs
Polypectomy
Ethmoidectomy

001903

Importance of Allergy Testing in the


Family Practice Setting
Distinguishes between allergic, nonallergic and mixed rhinitis
Aids in selecting specific pharmacotherapy
Identifies specific allergens to be avoided and/or treated by
immunotherapy when indicated

001903

Indications for Allergy Testing


Identification of allergens
Chronic or recurrent symptoms
Symptoms not controlled by avoidance and medication
Medication not tolerated
Decrease cost of medication

001903

Contraindications for Allergy Skin Testing


Uncontrolled asthma or recent asthma attack
PEFR must be above 70% personal best effort

Cardiac problems
History of hymenoptera sensitivity
History of anaphylaxis of any kind
Shellfish
Medications

001903

Refer to an Allergist
Hymenoptera sensitivities
Antibiotic desensitization
Anesthetic testing
Patients with history of anaphylaxis
Medication
Shellfish
Peanut or other food reactions

001903

Allergy Testing and Allergy


Screening in Family Practice
A very cost effective procedure
to learn

106

Allergy Testing in Family Practice


Easy to learn to perform
Results interpreted against negative and positive controls
Safe with good patient selection
Test results immediate
Patient can see, feel and scratch response
Aids in avoidance procedures

001903

Instruments Used in Allergy Testing


Invivo tests
Individual skin prick tests
DuoTip
Morrow Brown needle
GreerPick

Multiple antigen applicators


MultiTest
Quintest

Invitro tests
Modified in-vitro testing
CAP system

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Skin Testing Disadvantages


Affected by medications
Antihistamines
Steroids

Patient discomfort
Rare possibility of anaphylaxis
Dermagraphism
Chronic skin disorders
Very young and atrophic skin

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Puncture/Prick Testing
Disease-free site
Swipe with alcohol
Apply drop of antigen
(1:10 or 1:20 conc.)
Prick skin at 45 to 60 degree
angle, or puncture at 90 degrees
Gently lift device, no bleeding
should occur
Read positive control in
10 minutes
Read allergens in 15-20 minutes

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Figure 1

Example of a skin prick/puncture


epicutaneous test

Multiple Antigen Testing


Alcohol wipe and dry area to be used
Remove device from package
Place in loading dock
Apply to forearm
Read positive control in 10 minutes
Record allergen response in 15-20 minutes

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Multiple Antigen Testing


Figure 2

Example of multiple-puncture
device allowing simultaneous
placement of six allergens plus a
positive and negative control

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contd

Figure 3

Example of multiple-puncture
device in its loading dock

Multiple Antigen Testing


Figure 4

Example of application of a
multiple-puncture
device to the forearm

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contd

Figure 5

Example of positive and negative skin


responses to allergens applied with a
multiple-puncture device; note the
positive and negative control sites

Skin Testing Precautions


Physician always present
Emergency equipment available and current
Adrenalin and albuterol in testing room

Determine patients most recent use of antihistamines,


steroids, H2 blockers
Is patient on a beta blocker?
Switch medications or in vitro testing

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Grading of MultiTest

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No reaction-1-3 mm wheal

1+

Erythema with 3mm wheal

2+

Erythema with 5 mm wheal

3+

Erythema with 7-10 mm wheal

4+

Erythema with >10 mm wheal

5+

Erythema with >10 mm wheal and pseudopods

Reading and Recording Results


Best done by physician scoring and nurse recording
If reaction is borderline, read as the higher class
Example
Difficulty determining if result is #3 or #4 record as #4

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Positive and Negative Controls


Imperative to use to validate skin response
Positive negative control = dermagraphism
Negative positive control = medication reaction or
hypoactive skin

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In-Vitro Testing
Reference laboratory
Many available

In-office labs
Weigh expense involved

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Indications for In-Vitro Testing


Dermatographism
Eczema
Very young skin
Atrophic skin
Long-acting antihistamines
Beta blockers, ACE inhibitors, MAOs
Patients with poorly controlled asthma (70%)
History of anaphylaxis

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RAST Procedure
Allergen coupled to paper disc
Add patients serum
Antigen-antibody complex formed
Radioactive anti IgE added
Anti IgE-antibody-allergen complex formed
Gamma counter scoring

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RAST Scoring

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Class 0

200-500

No allergy

Class 0/1

500-750

Questionable allergy

Class 1

750-1,600

Mild allergy

Class 2

1,600-3,600

Moderate allergy

Class 3

3,600-8,000

More allergic

Class 4

8,000-18,000

More allergic

Class 5

Over 18,000

Most allergic

Advantages of In-Vitro
Patient safety, no anaphylaxis
Cost-effective screening
Not affected by medication
No irritating skin reactions
Sets safe starting doses for immunotherapy

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Disadvantages of In-Vitro
Patient does not experience the reaction
Less sensitive than skin tests (?)
Cost per test may be higher
RAST requires 3-14 days to get results

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RAST Scoring as a Guide to


Immunotherapy
The higher the RAST class the more dilute the starting
dose of immunotherapy
The lower the RAST class the higher the starting dose of
immunotherapy

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Prescribing Immunotherapy Based


on RAST Results
Blood sample is drawn anytime
Serum is removed
Sent to lab and processed
Results correlated with history
Prescription for immunotherapy written
Lab makes up immunotherapy sets

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Allergy Screening
A most cost effective test to do!

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Allergy Screening
Use of 6-10 antigens to determine the presence or absence
of allergy
Prevalence of sensitization
Same allergens common to patients in a geographic area
Incidence varies from 20% to 80% per antigen

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References
Nalebuff, DJ. Use of RAST screening in clinical allergy: a
cost-effective approach to patient care. Ear Nose Throat J.
1985; 64:107-21.
Blok et al. Reported use of 5 antigen screens. Allergy. 1991

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Screening Allergens-Most Common


from Geographic Area

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Negative control

Positive control

Weed (ragweed)

House dust mites

Grass (June)

Mold (alternaria)

Tree (oak or elm)

Cat

Typical Midwest Screen


Ragweed
House dust mite
Cat
June grass
Oak tree
Alternaria

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Interpretation of Screen
All tests negative (except positive control) no allergy is
present
Positive control and all other test sites negative,
hypoactive skin, proceed with in-vitro test
Any grass, tree, weed or mold positive
panel
House dust mite only positive
Cat only positive

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avoidance

complete allergy

avoidance

Advantages of Screen
Identifies the allergic and nonallergic
Eliminates need for unnecessary testing of nonallergic patients
Helps direct pharmacotherapy
Demonstrates antigens needing avoidance
Cost-effective, reliable

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Screening with RAST


6-10 antigens all placed on disc or in a cellulose
suspension and tested
When positive, additional antigens are tested, usually
25-35 for geographic area

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Geographic Allergy Panels


25-40 antigens
Unusual animal danders per history
Kniker T. MultiTest skin testing in allergy: a review of
published findings. Ann Allergy. 1993;71:485-91
Foods if indicated

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Cross-Reacting Pollens
June: rye, sweet vernal, timothy, brome, red top
Oak tree species
Hickory and pecan trees
Ragweed species

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Before Considering Immunotherapy


Always correlate history with test results.

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Indications for Immunotherapy


Inadequate control with avoidance and pharmacotherapy
Pharmacotherapy for more than 3-4 months per year
Intolerable side effects of medication
Progressive severity of disease
Desire for long-lasting control without Rx

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The Allergy Screen is Negative,


What Next?
Identify nonallergic triggers
Elimination diet to look for adverse food reaction
Use medications indicated for nonallergic rhinitis
Astelazine
Intranasal steroids
Decongestants
Antihistamines are of little value

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Bibliography
The Allergy Report. American Academy of Allergy,
Asthma and Immunology, Milwaukee, WI: 2000. Available
at www.aaaai.org.
Middleton E, et al. Allergy: principles and practices 5th ed.
St. Louis, Mosby: 1998.

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Bibliography
Altman LC, Becker JW, Williams PV. Allergy in Primary Care.
Philadelphia: Saunders; 2000.
Squillace S, Hedges H. Asthma, allergic rhinitis and
immunotherapy. American Academy of Family Physicians;
1998.
Kaliner MA, ed. Current reviews of rhinitis. Curr Med; 2002.

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Allergy Resources Available to


Family Physicians
American Academy of Family Physicians
1-800-274-2237
Antigen Laboratories
1-816-781-5222
Allergy Laboratories
1-800-654-3971
National Procedures Institute
1-800-462-2492
Pan American Allergy Society
1-210-997-9853

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Evidence-Based Recommendations
Practice Recommendation: Treat patients diagnosed as having allergic seasonal rhinitis
with prophylactic medications (antihistamines and/or intranasal corticosteroids).
Practice Recommendation: Prescribe intranasal corticosteroids to control allergic
rhinitis symptoms.
Practice Recommendation: Educate patients with allergic rhinitis about avoidance
activities.
Practice Recommendation: Reserve immunotherapy for patients with allergic rhinitis
for whom optimal avoidance measures and medication therapy are insufficient to
control symptoms.
All recommendations available at: http://www.icsi.org/knowledge/detail.asp?
catID=29&itemID=158.
Accessed August 2003.

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Thank You
This has been a presentation of the
American Academy of Family Physicians

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