Rhinitis

1. Rhinitis Allergic or Nonallergic Rhinitis? Taking the Questions Out of Diagnosis and Treatment

2. Presentation Facts • File size: approximately 1751 KB • Number of slides: 143 • This presentation was designed for the user to select sections for their own presentations, or to use in its entirety. • Evidence-Based CME: Web site addresses for all EB recommendations are available near the end of this presentation. • These slides were prepared by the AAFP and content should not be modified in any way. If content is changed, it is the user’s responsibility to remove both the AAFP and the CME logos. Instructions to remove logos: from menu, select VIEW, MASTER, SLIDE MASTER; select the logos and delete; to return to the original slide view, select VIEW, SLIDE

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

4. 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 MedicineUniversity of Virginia Health SystemCharlottesville, Virginia

5. 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

6. 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

7. 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.

8. Epidemiology and Prevalence

9. 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

10. Epidemiology Of Rhinitis • Allergic rhinitis was reported the second mostprevalent 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

11. 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

12. Daily Costs of Rhinitis production absenteeism diseases • 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?

13. 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

14. 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?

15. 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

16. 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

17. 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.

18. Annals of Allergy, Asthma, and ImmunologyVol 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

19. 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

20. 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)

21. Fatigue Concentration Nuisance Sleep disturbance Emotional well being Social interactions Missing school/work Halitosis Decreased daily production Impaired studying Sniffing/snorting Blowing nose Quality-of-Life Issues

22. Quality of Life in Seasonal Allergic RhinitisOverall RQLQ Fexofenadine 120 mg qd is significantly better than loratadine in improving quality of life with respect to SAR symptoms 0.0 -0.4 Change from baseline† (mean) -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.

23. Pathophysiology • Direct effects of histamine • Indirect effects of histamine • Other mediators of the immune response

24. 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.

25. 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

26. 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 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

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

28. 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.

29. 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?

30. 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?

31. 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

32. Bimodal Occurrence of Allergic Rhinitis • First appears in elementary school ages • Abates during middle and high school ages • Reappears in 20s and 30s

33. 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

34. Risk Factors for Rhinitis • Asthma, atopic dermatitis, allergy • Family history of allergy • Daycare centers • Viral infections • Occupational exposures • Hobbies, weekend activities • Flying

35. Allergy NARES syndrome Occupational Hormonal Drug induced Anatomic defects Irritants Adverse food reaction Emotional Atrophic Ciliary dyskinesia Immunodeficiency diseases Causes of Rhinitis

36. Allergic Rhinitis

37. 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.

38. Diagnosis: Typical Patient with Allergic Rhinitis with its Common Morbidities • Perennial allergic rhinitis with seasonal exacerbations • Recurrent otitis media • Asthma triggered by viral infections

39. Symptoms of Allergic Rhinitis • Sneezing • Nasal congestion • Watery nasal discharge • Itchy watery eyes • Postnasal drip • Itching

40. Physical Changes of Allergic Rhinitis • Pale blue, edematous turbinates • Clear, watery nasal discharge • Crease from nasal salute • Lymphoid hyperplasia • Watery, itchy eyes

41. Photo Image of Nasal Salute

42. 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

43. 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

44. Allergy History Screen

45. 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

46. Physical Examination • Eyes: conjunctivitis, dark circles, Dennie’s lines • Ears: OM, TM mobility, serous otitis • Mouth: mouth breathing • Lungs: wheezing

47. Nasal Smear • Clear nose of secretions • Gently scrape sample from mucosa of inferior or middle turbinate with plastic ear spatula or cotton swab • Wright’s or Hansel’s stain • Eosinophilia • Allergy (present in 90% of allergic patients) • NARES syndrome • Aspirin sensitivity • Neutrophilia • Infection

48. 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 • Water’s view for the maxillary sinuses • Town’s view for ethmoid and frontal sinuses • Lateral view for the sphenoid • Limited coronal CT scan (cost $397: local hospital) • Osteomeatal complex • All sinuses visualized • CT scan gives much better imaging for minimal increased cost

49. Photo Image of Rhinoscope

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