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RHINITIS

Literature Reading

T.HUSNI T.R

Dept of Otorhinolaryngology HNS


Hasan Sadikin General Hospital
Bandung
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Introduction

Inflammatory dis. of the nasal mucous membrane, and is


characterized by nasal congestion, rhinorrhea, sneezing,
itching of the nose and/or post nasal drainage
Dramatic rise in the incidence of rhinitis over the last two
to three decades urbanization and environmental
pollution may play a role.
A high prevalence of chronic rhinitis disorders clinician
became equipped to approach rhinitis knowledgeably and
systematically in order to permit accurate diagnoses and
effective therapeutic intervention
Rhinitis may be caused by allergic, non allergic,
infectious, hormonal, occupational and other factors.
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Introduction

Rhinitis is a significant cause of widespread


morbidity, medical treatment costs, reduced work
productivity and lost school day
quality of life.
Misconception that allergy processes root of all
chronic nasal disorder misdiagnoses and
inappropriate management
Directed clinical history and physical examination
combined with noninvasive and routine procedures
diagnose the conditions causing rhinitis
Systematic approach to diagnosing and treating
improve a patients quality of life and decrease the
economic impact
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Nasal Anatomy and


Physiology
Each nasal cavity is divided into specific regions, which include the
nasal vestibule, nasal septum, lateral nasal wall, and nasopharynx

Adapted from : Vining, E. Rhinitis. In : Bailey, B.J. Head &


Neck Surgery-Otolaryngology. 2nd ed. 1998

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Adapted from : Netter Atlas

Consists : 3 turbinate or conchae, covered by mucous


membrane
Below each of the turbinate meatus: 3-4 mm in size
susceptible to closure by even a small amount of mucosal
inflammation.

Adapted from : Vining, E. Rhinitis. In : Bailey, B.J. Head &


Neck Surgery-Otolaryngology. 2nd ed. 1998

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Adapted from : Netter Atlas

Nasal Vascularization

Adapted from : Netter Atlas

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Extensive sinusoidal network of large-capacitance vessels located in


the mucosa deep to the sub epithelial capillaries.
Primarily in the mucosa of the inferior turbinate and anterior
septum
Autonomic innervations of the nasal mucosal vasculature.

Adapted from : McCaffrey, T.H. Nasal Function and


Evaluation. In : Bailey, B.J. Head & Neck SurgeryOtolaryngology. 2nd ed. 1998

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Nasal Innervation
Sensory innervations of the nasal cavity occurs through the
ophthalmic and maxillary branches of the trigeminal nerve
and through the special sensory fibers of the olfactory nerve

Adapted from : Cummings, C.W. Otolaryngology H&N surgery. 2nd ed. 19


Adapted from : Vining, E. Rhinitis. In : Bailey, B.J. Head &
Neck Surgery-Otolaryngology. 2nd ed. 1998

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The autonomic nervous system supplies both parasympathetic


and sympathetic fibers, which act to regulate the degree of
vascular tone, turbinate congestion, and nasal secretion

Adapted from : Vining, E. Rhinitis. In : Bailey, B.J. Head &


Neck Surgery-Otolaryngology. 2nd ed. 1998

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Nasal Mucociliary Transport

Mucosa pseudostratified,
ciliated columnar epithelium
and is contiguous with
paranasal sinuses,
nasopharynx, and middle ear.
Mucosal epithelium : ciliated
columnar cells, nonciliated
columnar cells, goblet cells,
and basal cells.
Submucosa contains stromal
cells, inflammatory cells,
nerves, blood vessels, and
seromucous glands
The columnar cells are
covered by microvilli 300400 on each cell.
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Mucous Blanket

The mucous layer of the respiratory passages was not


homogeneous two-layer structure of the mucous layer.
The direction of transport follows a pattern determined by
the orientation of the cilia beat.

Adapted from : McCaffrey, T.H. Nasal Function and


Evaluation. In : Bailey, B.J. Head & Neck SurgeryOtolaryngology. 2nd ed. 1998

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Cilia essential for the


normal flow of the mucous
blanket
Most columnar epithelial cells
ciliated, + 200 cilia/cell,
beat + 1,000 x/min.
Each cilium consists of an
epithelial membrane
enclosing a multi structured
axonema
Disorders of cilia or ciliary
dyskinesias characterized
by abnormalities in ciliary
structure or function leading
to ciliary immobility and
mucous stasis

Adapted from : Krause, H.H. Nasal


cytology in clinical allergy. In :
Otolaryngic Allergy and Immunology.
1989
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Nasal Physiology

The complex anatomy and physiology of the nose


many important functions: breathing,
conditioning and filtration of air, olfaction, and vocal
resonance.
Adults breathe 10,000 to 20,000 L of air per day,
the majority of which passes through the nose.
Conditioning of this air is controlled through
changes in nasal blood flow, resistance, and
secretions.
In addition, infectious, allergenic, irritative, or toxic
materials are further filtered and eliminated
through the function of the mucosa and the mucous
blanket that it produces.
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Classification of Rhinitis

Infectious

Viral
Bacterial
Other infectious agents

Allergic

Aspirin
Other medications

Intermittent
Persistent

Drug induced
Hormonal
Other causes

Occupational (allergic
and non allergic)
Intermittent
Persistent

NARES
Irritants
Food
Emotional
Atrophic
GERD

Idiopathic

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Adapted from : ARIA 2001

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Differential Diagnosis of
Rhinitis

Polyps
Mechanical factors

Wageners
granulomas
Sarcoid
Infectious
Malignant midline
granulomas

Deviated septum
Adenoidal
hypertrophy
Foreign bodies
Choanal atresia

Tumors
Benign
malignant

Granulomas

Cilliary defects
CSF rhinorrhea

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Adapted from : ARIA 2001

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Classification of Rhinitis

Allergic rhinitis

Reflex Induces Rhinitis :

Non Allergic Rhinitis

Occupational

Seasonal
Perennial
Episodic
Occupational

Infectious
Acute
Chronic

NARES syndromes
Perennial non allergic rhinitis
(vasomotor rhinitis)
Other rhinitis syndromes :

Cilliary dyskinesia syndrome


Atrophic rhinitis
Hormonal induced rhinitis

Hypothyroidism
Pregnancy
Oral contraceptives
Menstrual cycles

Exercise
Drug induced Rhinitis

Rhinitis medicamentosa
Oral contraceptives
Anti hypertensive therapy
Aspirin
NSAID

Gustatory rhinitis
Chemical or irritant induced
Posture reflexes
Nasal cycle
Emotional factors

Other Condition that may


mimic symptoms of rhinitis

Structural/mechanical factors

Deviated septum/septal walls


anomalies
Hypertrophic turbinates
Adenoidal hypertrophic
Foreign bodies
Nasal tumors
Choanal atresia

Inflammatory/immunologic

Wegeners granulomatosis
Sarcoidosis
Midline granuloma
systemic lupus
erythematosus
Sjogrens syndrome
Nasal polyposis

Cerebrospinal fluid rhinorrhea16


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Infectious Rhinitis

Incidences :
Acute viral rhinosinusitis most common health
complaints, affecting millions people annually
0,5 2 % viral URTI acute bacterial infections
Chronic rhinosinusitis 5 15% urban population

Four principal clinical types :

Acute
Recurrent acute
Chronic
Acute exacerbations of chronic disease
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Etiologies :

Acute infectious :

Viral : rhinovirus, influenza, parainfluenza


Bacteria : Strep. pneumoniae (20-35%), Haem. influenza
(6-26%), Mor. catarhhalis, Staph. aureus, anaerob bacteria

Chronic infectious :

Bacteria : same bacteria in high titrates

Fungi : Aspergillus fungi, Alternaria, Bipolaris


Others : M. tuberculosis, Kleb. Rhinoscleromatosis,
M. leprae, Trep. Pallidum

Cilliary abnormalities, immunodefficiency,


and direct trauma may all predispose
individuals acute and chronic infection
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Symptoms of acute infection :


Initial : clear, watery rhinorrhea, sneezing, NO,
facial pain, ear fullness
Nasal drainage cellular and cloudy :
Presence of organisms, white blood cell, desquamated
epithelium

Self limiting and usually resolves within 7-10 days


Acute bacterial follow viral rhinitis
NO, cloudy drainage, vestibular crusting and facial pain

Symptoms persisting longer than 2 weeks


search for causes other than infection
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Chronic Infections :

Controversy about whether chronic


infectious rhinitis can exist in the absence
of chronic sinusitis
Symptoms of chronic infections
NO, predominantly purulent nasal discharge,
facial pain and pressure, olfactory
disturbances, and post nasal drainage with
cough

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NARES (Eosinophilic Rhinitis)

Heterogeneous syndromes : NARES and Aspirin


intolerance
Characterized by :
Perennial symptoms of sneezing, itching, profuse watery
rhinorrhea, nasal obstruction and loss of sense of smell
Presence of nasal eosinophilia during symptomatic
period
Absence of demonstrable allergy

NARES 3 stages :
Migration of eosinophils from vessels to secretions
Retention of eosinophils in the mucosa which might be
linked to activation of unknown origin
Nasal polyposis
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Perennial non allergic rhinitis


(without eosinophilia)

~ vasomotor rhinitis perennial rhinitis


whose symptoms are intensified by non
specific environmental triggers
Non allergic non infectious rhinitis, non
associated with nasal eosinophilia
Implies increased neural effect traffic to the
blood vessels supplying nasal mucosa
Symptoms 2 group :
Runners (cholinergic rhinitis) wet rhinorrhea
Dry predominant nasal congestion and blockage
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Atrophic rhinitis

Primary atrophic rhinitis characterized by :


Progressive atrophy of the nasal mucosa and underlying
bone
Full of copious foul smelling crusts

Etiology : Klebsiella ozaenae primary pathogen


Symptoms :
Nasal obstruction, hyposmia, and a constant bad smell

Distinguish from secondary atrophic rhinitis


associated with chronic granulomatosis
conditions, excessive nasal surgery, radiation and
trauma
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Hormonal Rhinitis

Occur during the menstrual cycle, puberty,


pregnancy, and in specific endocrine
disorders such as hypothyroidism and
acromegaly
Postmenopausal women :
Hormonal imbalance atrophic nasal change

Last trimester pregnancy :


Persistent hormonal rhinitis
Parallels the blood estrogens level
Syndromes disappear at delivery
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Drug Induced Rhinitis

Aspirin and NSAID


Characterized by nasal secretion, eosinophilia, frequent
occurrence of polyps, sinusitis, non allergic asthma,
Good response to glucocorticoids

Other medications :
Reserpine, guanethidine, phentonolomine, methyldopa,
ACE inhibitors, adrenoreceptor antagonists, intra ocular
ophthalmic, chlorpromazine, oral contraceptives

Rhinitis medicamentosa
Rebound nasal obstruction which developes in patients
who use intranasal vasoconstrictors chronically

Cocaine sniffing
Associated with frequent sniffing, rhinorrhea, diminished
olfaction and septal perforation
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Occupational Rhinitis

Refers to rhinitis arising in response to an


airborne substances in the workplace
mediated by allergic or non allergic
Triggering substances :
irritants :
Tobacco smoke, cold air, formaldehyde, hair sprays

IgE mediated :
Laboratory animals, Grains, Wood dust, Particularly
hard woods, Latex and chemicals

Occupational rhinitis may precede


development of occupational asthma
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Symptoms may occur acutely at work after


intermittent exposure or more chronically
at work after continues exposure
The optimal management :
Avoidance of the occupational trigger
Pharmacologic therapy :
Daily use of antiinflammatory intranasal
corticosteroids or antihistamines and/or intranasal
cromolyn immediately prior to allergen exposure

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Food induced rhinitis

Induced symptoms by unknown non allergic


mechanism vagally mediated
mechanism, nasal vasodilatation, food
allergy and/or other undefined
mechanisms.
Rare cause of rhinitis without associated GI
tract, dermatologic or systemic
manifestations
Food skin tests may be appropriate in
occasional cases
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Alcoholic drinks produce symptoms by


nasal vasodilatation
Hot and spicy food syndrome of copious
watery rhinorrhea gustatory rhinitis,
which vagally mediated

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Other condition that


Mimic Symptoms of Rhinitis

Sign and symptoms suggestive of rhinitis


can be produced by other conditions
including : nasal septal deviation, tumors,
adenoidal hypertrophy, hypertrophy of the
nasal turbinates
Prolonged occupational exposure to
chemical associated with hypertrophic
rhinosinusitis, metaplasia and carcinoma
Refractory clear rhinorrhea CSF leak even
in the absence of trauma or recent surgery
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Diagnostic Approach

Medical History
Physical examination
Radiology Imaging
Nasal endoscope
Nasal cytology
Others :

Testing for specific Ig E


Aerodynamic methods
Nasal provocation testing
Mucociliary clearance, and
Pulmonary function tests.
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Medical History
Plays an important role in guiding both further testing and
appropriate medical and surgical therapy.
Age of presentation and the duration of the complaint
along with other systemic symptoms and provoking
factors may narrow the differential diagnosis immediately.
Patients should be questioned about allergic triggers,
previous surgery, trauma, use of nasal sprays or illicit
substances (i.e., cocaine or heroin), and the presence of
epistaxis or drainage.
Laterality of symptoms lends important information
regarding etiology.

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Symptoms of rhinitis also appear as side effects of


systemically administered pharmacologic agents

Evaluated for systemic illnesses that may


predispose them to these infections.

Several other systemic diseases may have a


predilection for affecting the tissues of the nose and
lower airways as a part of a symptom complex.
Physical stimuli may also trigger rhinitis.

Include inhalation of cold and dry air, ingestion of hot food,


or exposure to bright light.
These stimuli-symptom reactions have been experimentally
reproducible; however, effective treatments remain elusive.
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Important Historical Points

Adapted from : Dykewicz, M.S. Diagnosis and


Management of Rhinitis. In : Ann Allergy Astma Immunol.
1998

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Taking History of
Impact on Quality of Life

Symptoms of rhinitis may significantly


impact the patients quality of life, by
causing fatigue, headache, cognitive
impairment and other systemic symptoms
An assessment of the degree to which
these symptoms interfere with the
patients ability to function should be
made

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Physical Examination

A complete H&N examination essential


evaluation
General facial appearance signs of
chronic nasal obstruction and mouth
breathing.
The patients voice should be carefully
listened to for hyponasal speech.

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Element of Physical Examination and Procedure to


Consider in Patients with Rhinitis

Adapted from : Dykewicz, M.S. Diagnosis and


Management of Rhinitis. In : Ann Allergy Astma Immunol.
1998

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Nose

The appearance of the external nose any


external deviation that may indicate an
underlying septal deformity.
A saddle deformity, usually a sign of loss of septal
support, is a late complication of trauma or of
chronic inflammatory processes
Tip ptosis or a collapsed nasal valve further
sign of loss of external support and associated
with nasal obstruction.
Hypertelorism due to widening of the nasal
dorsum can occur with severe nasal polyposis.

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Anterior Rhinoscopy
Provides a view of the anterior one-third of
the nose
General appearance of the nasal mucosa
including color, thickness, and presence of
secretions should be appreciated.
The turbinates should be examined for size,
color, ulceration, granulation, crusting, or
polypoid changes.
The nasal septum should be inspected for
evidence of deviation or perforations as well
as crusting.

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Nasal Endoscopy

One of the major contribution to understanding


of the pathology of the nose and sinuses
The development of the rigid nasal telescope
has dramatically improved the clinicians
ability to examine entire nasal cavity
Clinician is afforded views of the mucosa
throughout the nasal cavity in areas such as
the middle meatus, sphenoethmoidal recess,
and olfactory cleft, which are inaccessible to
anterior and posterior rhinoscopy

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Nasal Endoscopy

Three mean areas for which endoscopy


can be used :
Diagnosis
Considerable variety of anatomical and pathological
abnormalities can be demonstrate

Treatment
The act of aspirating secretion may in itself constitute
therapy, and certainly irrigation can be performed
Endoscopic surgery

Documentation

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Nasal Endoscopy

Hardware :
A number of light source of varying power and cost
Flexible nasoendoscope and nasopharyngoscope
Rigid nasal telescope

Technique
Well tolerated by an awake patient pretreated with a topical
decongestant and anesthetic.
The procedure may be performed with the patient sitting or
supine
Endoscopic examination of nasal cavity and nose lateral wall,
accomplished 3 steps:
Inspection nasal vestibule, nasopharynx, inferior nasal meatus
Examination sphenoethmoidal recess, superior nasal meatus
Examination of middle meatus
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Nasal Cytology

Studies of the cellular patterns of nasal secretions


or tissues often provide helpful information
evaluating the patient with symptoms of chronic
rhinitis.
Nasal cytology various cell types are
characteristic
A specimen is obtained by scraping the inferior
turbinate with a small curet analysis of the
different cell types and ciliary motility can be
assessed.

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Specimen Technique :

- Blown secretions cell or


epitels secrete
- Smears inferior turbinate
- Imprins
- Brush
- Nasal scraping Rhinoprobe
- Nasal Lavage
- Biopsy mucosa, basal
membrane, sub mucosa
Adapted from : Krause. Nasal Cytology
in Clinical Allergy. In : Krause.
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Otolaryngic Allergy and Immunology.

Nasal Cytology
Stain Techniques
Hansels
Wright-Giemsa
Basofil
Papanicolaou
Toluidine blue
Leishmans
Alcian yellow
Randolphs
Alcian blue
May-Grunwald

Eosinofil
Eosinofil, Neutrofil, and
Epitel, nukleus, cytoplasm
Basofil
Eosinofil
Mast cell
Eosinofil
Basofil
Netrofil
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Grading Nasal Cytogram

Adapted from : Meltzer, E.O.


Cytology. In : Mygind, N. Allergic
and Non-Allergic Rhinitis Clinical
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Aspects. 1993

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Guide for Interpreting of the Nasal Cytogram

Adapted from : Meltzer, E.O.


Cytology. In : Mygind, N. Allergic
and Non-Allergic Rhinitis Clinical
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Aspects. 1993

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Nasal Cytology in Various Clinical Conditions

Adapted from : Meltzer, E.O.


Cytology. In : Mygind, N. Allergic
and Non-Allergic Rhinitis Clinical
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Aspects. 1993

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MANAGEMENT

Chronic rhinitis nonpharmacologic,


nonsurgical therapies :

patient education and support,


environmental control,
nasal irrigation, and
exercise

Pharmacologic agents mainstay of


treatment, used either alone or in combination.
The five main classes of medications : H1 receptor
antagonists (e.g., antihistamines),
sympathomimetic agents, anticholinergics,
cromolyn sodium, and corticosteroids.
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H1 Receptor Antagonists

Mechanism of actions :

Block uptake of histamine by target cell


receptors, such as nasal blood vessels, mucous
glands, and pruritus receptors.
Inhibit release of inflammatory mediators from
sensitized mast cells and basophils .

They do not reverse any action already


taken by histamine work best when taken
daily during periods of allergen exposure.
Effective in controlling nasal itching,
rhinorrhea, and sneezing; they are less
effective at controlling nasal congestion.
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Pharmacocynetics :
Well absorbed orally, peak serum concentrations
in about 2 hours.
Half-life elimination a few hours to 14 to 18
days
Maximal antihistamine effects occur several
hours after serum concentrations have peaked
and persist even when serum levels are quite low.

Type of antihistamines :
first-generation (sedating) and
second-generation (nonsedating)
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Sedating Antihistamines

Sedative and anticholinergic effects most of the


adverse side effects.
Since these agents are nonprotein-bound, they cross the
bloodbrain barrier and bind to central H1 receptors,
producing sedation.
The incidence of sedation may be as high as 20% with
some of these agents, although the incidence of
decreased alertness is probably even higher.
In addition, the anticholinergic effects of these agents
cause urinary retention, excessive drying, and visual
complaints.
Long-term administration of first-generation
antihistamines may be associated with decreased
efficacy over weeks or months;
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2nd gen. antihistamines

Such as terfenadine and astemizole, are


lipophobic and do not cross the blood
brain barrier.
Comparable in efficacy to first-generation
agents like chlorpheniramine but are
without the sedative and anticholinergic
effects.
Other advantages preferential binding
to peripheral H1 receptor over central ones
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Intra Nasal Antihistamines

Effective for treatment of allergic rhinitis


May help reduce nasal congestion
A bitter taste and because significant
systemic absorption associated with
resultant sedation
Astelin (azelastine hydrochloride) :

1st intranasal antihistamine


OOA : within 3 hours versus placebo
Has been report reduce nasal congestion
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Adrenergic Drugs (Decongestan)

The two main families of adrenergic drugs :


Phenylamines (e.g., ephedrine, pseudoephedrine,
phenylephrine, phenylpropanolamine)
administered orally
1-adrenergic receptors, effecting mucosal capacitance vessels

Imidazolines (e.g., xylometazoline, oxymetazoline, naphazoline,


antazoline)
applied topically.
tend to effect 1- and 2-adrenergic receptors and decrease nasal
mucosal blood flow.

Net effect decrease mucosal congestion and edema.


They do not prevent itching and sneezing.
Potent vasoconstrictors, and when used for more than 5
to 7 days rebound congestion, upon withdrawal of
the drug
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Side effects :
Topical -adrenergic agents
do not generally cause tachycardia or hypertension.
Can lead to rebound nasal congestion (rhinitis
medicamentosa) which ussually occur after 5-10 days
of treatment

Oral -adrenergic agents


nervousness, insomnia, irritability, headaches,
palpitations, tachycardia, and urinary retention.
They are contraindicated in patients with hypertension,
severe coronary artery disease, and those taking
monoamine oxidase inhibitor therapy.
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Anticholinergic Drugs

Drying agents, useful in the management of


rhinorrhea that is predominantly cholinergically
mediated, but have no effect on other nasal
syndrome Ipratropium bromide (Atrovent)
Mechanisms of Action :

Affects the parasympathetically innervated


submucosal seromucous glands with very little
systemic absorption.
Useful in patients whose chief problem is rhinorrhea,
vasomotor rhinitis, or rhinitis induced by cold, dry air,
irritants, or viruses.
Reduction in rhinorrhea is further potentiated when
used in conjunction with antihistamines and topical
corticosteroids
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Special precautions :
Use in patients with narrow-angle glaucoma,
prostatic hypertrophy, and bladder neck
obstruction coz of the small risk of systemic
absorption.

Side Effect :
The most common side effects have been
nasal drying and epistaxis.

Doses :
2 sprays (42mcg) per nostril 2 or 3 times daily
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Topical Glucocorticoids

Most effective medication class in


controlling symptoms of rhinitis
Mechanisms of Actions anti
inflammatory activity
inhibit multiple steps in the inflammatory process
cause vasoconstriction,
decrease glandular response to cholinergic stimulation,
interfere with arachidonic acid metabolism,
reduce mediator release,
decrease production of cytokines from T lymphocytes,
and
inhibit the influx of eosinophils to the nasal epithelium
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Some of the topically active glucocorticoids include :

beclomethasone dipropionate,
budesonide,
dexamethasone,
flunisolide acetate,
fluticasone propionate, and
triamcinolone acetonide

Budesonide and fluticasone most topically potent,


using a vasoconstrictor index of potency.
Within the dosage range recommended minimal
evidence for systemic effect of these topical sprays
because of low systemic absorption and first-pass
metabolism through the liver.
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Nasal steroid sprays effectively reduce nasal mucosal


congestion, sneezing, and rhinorrhea. Once or twice
daily dosing is sufficient for the steroid sprays.
Side of Effects :
Dexamethasone is infrequently prescribed because of its
high systemic absorption and its suppression of the adrenalpituitary axis.
Bleeding from the anterior septum has been reported and
usually can be minimized by directing the spray away from
the septum, using aqueous forms, or using lower-velocity
sprays.

These agents have also been useful in treating


eosinophilic nonallergic rhinitis, rhinitis
medicamentosa, and nasal polyposis.
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Oral Glucocorticoids

Most potent therapeutic agents of allergic diseases


and can play a critical role in acute exacerbations
of allergic rhinitis, nasal polyposis, and NARES.
Effective discontinuation of topical
sympathomimetics in patients with rhinitis
medicamentosa.
Many serious side effects related to both dose
and duration of therapy.
In adults, side effects are usually minimal if the daily
dosage is less than 7.5 mg of prednisone.
Include weight gain, cushingoid habitus, easy bruisability,
glucose intolerance, osteoporosis, emotional changes,
suppressed hypothalamic pituitary adrenal function,
gastrointestinal symptoms, edema, hypertension, and
hypokalemia.
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Although the four classes of drugs


discussed here are quite effective, reasons
for treatment failure should be considered.
incorrect diagnosis, failure to address the
primary symptoms (e.g., rhinorrhea, sneezing,
congestion) with the drug designed to relieve
them,
lack of compliance,
inability to inhale the medication, and
overwhelming exposure to allergens or irritants.
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Rhinitis affects millions of Americans every year


high health care costs.
Although it is generally not a life-threatening
disease, sufferers of chronic rhinitis a real
decrement in their quality of life.
The autonomic nervous system with its regulation
of the nasal microvasculature plays a major role in
rhinitis pathophysiology.
Major functions of the nose are olfaction, provision
of an airway, air conditioning, protection against
infection, and self-cleansing.
There are many causes of nonallergic rhinitis
must keep this in mind to effectively diagnose and
treat patients with chronic rhinitis.
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In addition to a thorough physical examination,


nasal smear cytology, special stains, and culture
important in establishing the cause of chronic
rhinitis.
Pharmacologic treatment of rhinitis remains the
therapeutic mainstay. Understanding the
indications and side effects of these drugs results
in proper application and satisfactory relief of
symptoms.
Effective surgical procedures exist for the
obstructing, hypertrophied turbinate and for
patients with severe vasomotor rhinitis
unresponsive to medical management.
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Rhinoscleroma, syphilis, tuberculosis, and fungal


infections considered in the differential diagnosis
of chronic rhinitis refractory to the usual treatments.
Other noninfectious lesions nasal crusting and
ulceration : Wegeners granulomatosis, polymorphic
reticulosis, Churg-Strauss syndrome, and
neoplasms.
Although there are possible hormonally induced
effects, rhinitis during pregnancy is usually caused
by other underlying conditions.
New techniques and medications are being
developed that hold great potential for the diagnosis
and treatment of chronic rhinitis.
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