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Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish

Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish. Concord Rhinology, Allergy and Skullbase Surgical Unit. Evening Outline. Dr Arj Ananda Interpreting a CT scan of the sinus Dr Larry Kalish Allergic rhinitis - Diagnosis and Management Assoc Prof Ray Sacks

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Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish

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  1. Assoc Prof Ray SacksDr Arj AnandaDr Larry Kalish Concord Rhinology, Allergy and Skullbase Surgical Unit

  2. Evening Outline • Dr Arj Ananda • Interpreting a CT scan of the sinus • Dr Larry Kalish • Allergic rhinitis - Diagnosis and Management • Assoc Prof Ray Sacks • Surgical management of Allergic Rhinitis

  3. Allergic Rhinitis Diagnosis and Management Dr Larry Kalish MBBS (Hons I), MS, MMed(Clin Epi), FRACS Concord Hospital ENT department Sydney Sinus and Allergy Centre

  4. Overview • Definitions • Epidemiology • Unified airway • Aetiology • Diagnosis • Investigations • Management

  5. Definitions • Atopy • inherited predisposition to produce IgE to environmental allergens • 40% of Australasian population is atopic • All patients with allergic rhinitis are atopic • Allergic reaction • exaggerated or inappropriate immune reaction which causes damage to the host • Rhinitis= inflammation of the nose and sinuses • Classified by aetiology • Allergic • Non-allergic

  6. Rhinitis - classification Allergic Non-allergic Infectious Idiopathic or vasomotor Drug-induced • (medicomentosa, OCP, cocaine, antihypertensives, NSAIDs etc) Hormonal • rhinitis of pregnancy, menstruation, menapause, Endocrine • Hypothyroidism, diabetes Rhinitis of no airflow Atrophic - primary vs secondary Eosinophilic rhinitis Other systemic disorders Traumatic - thermal, chemical, physical

  7. AR - Epidemiology • The prevalence of allergic rhinitis is increasing. • Approximately 16% of Australians have allergic rhinitis, • including: • about 19% of working-aged adults • about 25% younger adults (25–44 years) • about 20% of adolescents (13–14 years) • about 12.5% of primary school children (6–7 years) • Approximately 10% of all Australians and 14–16% of Australian children have asthma.

  8. AR - Epidemiology • Rhinitis occurs in an estimated 75–80% of patients with asthma, with high rates reported in both atopic and non-atopic asthma. • Conversely, 20–30% of patients with known allergic rhinitis also have asthma. • Allergic rhinitis is now a recognised as a risk factor for developing asthma

  9. Hygiene Hypothesis • The most unifying hypothesis = “Hygiene hypothesis” • Suggests that a Cleaner environment (eg less exposure to bacteria, use of vaccines and antibiotics etc) predisposes to the persistence of an allergic phenotype in early childhood

  10. Unified Airway Theory • The Nasobronchial Reflex, • Sino-nasal protection of the lower airway • Shared inflammation within a unified airway • Aspiration of infected or inflammatory sinonasal secretions - UNSUPPORTED

  11. AR - Aetiology

  12. Inhaled Allergens • Particles which elicit an allergic response • Identified by their portal of entry via the respiratory tree which is richly supplied with IgE. • Essentially all inhalant allergy is IgE mediated, producing a Type I hypersensitivity reaction.

  13. Hypersensitivity • Type I- Immediate Hypersensitivity • Immediate • Allergen binds 2 molecules of IgE • Intracellular degranulation and immediate release of products • Ex. Allergic rhinitis, anaphylactic shock, asthma

  14. From: kay: New England J of Medicine Vol 344(1). Jan 4, 2001. 30-37

  15. Two Phases • “Early Phase” response • 10-30mins after allergen exposure • Mast cells degranulate • Vascular leakage / interstitial oedema • irritation of sensory nerves - Nasal pruritis, rhinorrhea, nasal congestion and sneezing • “Late Phase” response • 4-8 hours later • chemotaxis and migration of neutrophils, basophils, eosinophils, T-lymphocytes, and macrophages across the mucosal endothelium into the nasal submucosa.

  16. Allergens • Seasonals • Pollens • Trees - ~ late winter - early spring • Grasses - ~ summer • Weeds - ~ end of summer / autumn • Perennials • Dust mites • Moulds - Alternaria, Aspergillus • Cockroach allergens • Dog and Cat dander

  17. AR - History • If you don’t ask they won’t volunteer • Classical Symptoms include • itchy eyes, nose, throat • sneezing, BEWARE the reactive NOSE • rhinorrhea, congestion, • Other symptoms • headache, loss or diminished smell or taste, postnasal drip, headaches, nocturnal cough, halitosis, mouth breathing, hoarse voice, sore throats and snoring. • Children • Throat clearing in kids without nasal symptoms • Allergic salute, nasal twitch • Nocturnal cough, morning fatigue, “silent sleep apnea”

  18. Remember • Patients can mistake symptoms of allergy for asthma • Classical symptoms common BUT not always present • Watch out for rhinorrhea and blockage alone

  19. AR - History • Onset, duration and pattern of symptoms over the day or year - see table • Family and personal history of allergic conditions, e.g. asthma, atopic dermatitis • Triggering and relieving factors • Medications (including alternate medications) • Home, work and leisure environments • Systemic symptoms (e.g. daytime fatigue).

  20. Classification

  21. AR - Physical Exam • Nasal mucosa • pale/bluish, congested, boggy - covered by watery mucosa. • Eyes • Dennie Morgan lines (Infraorbital oedema), allergic shiner / lashes • Other • Open mouth breathing, nasal crease, high arch palate, teeth crowding, posterior pharyngeal cobblestoning

  22. Be mindful of • Unilateral nasal discharge • Purulent / bloody • Foreign body until proven otherwise • Clear / straw colored • CSF leak until proven otherwise

  23. Be mindful of • Nasal polyps • Difficult to treat eczema, food allergies or poorly controlled asthma • Persistent non-classical symptoms and signs for more than 12 weeks = Chronic CRS

  24. AR - Investigations Allergy testing • To confirm diagnosis • To give avoidance advice • Targeted immunotherapy Indications • Those patients who fail medical trial • Identify those patients likely to benefit from immunotherapy

  25. AR - Investigations • Skin Prick (epicutaneous) • RAST • nasal provocation test • total IgE

  26. Remember • “Regardless of diagnostic test the clinical correlation with inhalant trigger is crucial” • Food allergies DO NOT cause allergic rhinitis • Nasal sx in reaction to food is NOT allergy but irritation or chemical intolerance • Rhinitis in response to fumes, temperature or climate change is NON-allergic

  27. Management Hayfever = asthma of the nose Patients need to appreciate this concept

  28. AR - management • Allergen avoidance • Pharmacotherapy • Immunotherapy • Surgery

  29. Multimodality treatment The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)

  30. How can we get rid of Allergens? • Don’t recommend unless allergen known to be significant contributor to symptoms • And does it work • Level 4 evidence for most avoidance techniques • Dehumidifiers, A/C, acaracide sprays - no effect • HEPA filter, mattress protectors, removal of carpet • Reduce allergen but NO clinical benefit in adults ONLY kids

  31. Allergen Avoidance • Dust mites • Encase mattress, box spring, and pillow in allergen impermeable covers. • Wash bed linens weekly in hot water >50oC (caution with potential scalding in small children) • Reduce clutter/toys/collections in bedroom • Reduce indoor humidity to <50% • Replace carpet with polished floor (ie, wood, vinyl) • Replace upholstered furniture with leather, vinyl, wood, or plastic or wash regularly • Vacuum with high efficiency particulate air (HEPA) filters or dust weekly with mask

  32. Allergen avoidance • Animal dander • Removal of animal from home • If removal is not an option: • Keep animals outside or out of child’s bedroom • Change and wash clothes after animal contact • Use high-efficiency particulate air filters (eg, HEPA) • Bathe animal 2 /week or weekly • Wash cages or litter box frequently • Cockroaches • Reduce cockroach food supply by encasing food and disposing of garbage rapidly • Restrict access (seal entry sources) • Apply insecticides or exterminate professionally

  33. Allergen avoidance • Indoor mold • Eliminate damp areas and avoid high humidity • Repair water leaks • Clean moldy areas • Limit house plants and exclude from bedroom • Avoid humidifiers • ARE THESE MEASURES PRACTICAL ?

  34. Minimize allergen load • Regular nasal irrigation • Normal saline irrigation • Aim to physically wash out allergens • May improve drug delivery • May improve mucociliary clearance

  35. Drugs • Inhaled Nasal Corticosteroids • Antihistamines - topical and systemic • Anticholinergic sprays • Leukotrienes Inhibitors • Alpha-adrenergic agonists - decongestants • Mast-cell stabilizer • Systemic and Intraturbinal Corticosteroid injections

  36. Drugs • Preventers • Inhaled Nasal Corticosteroids • Mast-cell stabilizer • Leukotrienes Inhibitors • Relievers • Antihistamines - topical and systemic • Anticholinergic sprays • Emergency • Systemic Corticosteroids

  37. Drug treatment

  38. Intranasal Corticosteroids • Mometasone (Nasonex) • Fluticasone (Avamys, Becanase Allergy, Flixonase) • Bioavailability of <1% • Better affinity to glucocorticoid receptor • Budesonide (Rhinocort) • Beclomethasone (Becanase) • All no effect on HPA axis • Primarily block the late phase reaction. • Only a small fraction is absorbed locally • Side effects • Epistaxis 5-8%

  39. Antihistamines - oral • Compete with Histamine for the H1 receptor. • also change the three dimensional configuration of the receptor, decreasing its affinity for histamine and down-regulating histamine-driven symptoms • Most effective when taken prophylactically • Non lipophilic second generation - do not cross the blood-brain barrier = minimal sedative effects. • Different classes may be more effective between differing individuals. • Most effective at reducing symptoms of sneezing, nasal itching, and rhinorrhea.

  40. Antihistamines - topical • Levocabastine (Livositin) • Azelastine (Azep) • RAPID onset • Symptomatic relief • DIAGNOSTIC in my practice • Occular preparations • Livsotin / Azep • Patanol - antihistamine + mast cell stabilizer

  41. Other Management Options • Surgery • Turbinoplasty • Vidian neurectomy • Posterior neurectomy • Septoplasty • FESS • Immunotherapy • Subcutaneous • Sublingual

  42. Immunotherapy • Specific allergen immunotherapy • Effective in the Mx of asthma and AR • Can achieve durable remission of allergic sx • May reduce risk of childhood allergy progressing to asthma • Best given when there is evidence of AR predominantly due to single allergen • SLIT (sublingual) • SCIT (subcutaneous)

  43. SCIT • Subcutaneous injections • Weekly to monthly for 2-3 yrs • Adverse effects • Injection-site reactions • Sneezing • Bronchospasms • Urticaria • Anaphylaxis • Contraindicated • Severe or ustable asthma or pts on Beta blockers

  44. SLIT • Self daily administration • Relatively expensive • Limited but improving evidence • Probably longer to work 3-5yrs • SAFER

  45. The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)

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