Assoc Prof Ray Sacks Dr Arj Ananda Dr Larry Kalish

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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
 Surgical management of Allergic Rhinitis
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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
Overview
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Definitions
Epidemiology
Unified airway
Aetiology
Diagnosis
Investigations
Management
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
Allergic
Non-allergic
Rhinitis - classification
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
AR - Epidemiology
 The prevalence of allergic rhinitis is increasing.
 Approximately 16% of Australians have allergic rhinitis,
 including:
 about 19% of working-aged adults
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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.
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
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
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
AR - Aetiology
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.
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
From: kay: New England J of Medicine Vol 344(1). Jan 4, 2001. 30-37
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.
Allergens
 Seasonals
 Pollens
 Trees - ~ late winter - early spring
 Grasses - ~ summer
 Weeds - ~ end of summer / autumn
 Perennials
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Dust mites
Moulds - Alternaria, Aspergillus
Cockroach allergens
Dog and Cat dander
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”
Remember
 Patients can mistake symptoms of allergy for
asthma
 Classical symptoms common BUT not always
present
 Watch out for rhinorrhea and blockage alone
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).
Classification
Duration
Symptoms
Intermitte
nt
<4days / week
OR
< 4 weeks
Mild
NORMAL
SLEEP and
minimal
impairment of
daily activities
Persistent
>4 days / week
OR
>4 weeks
Modsevere
ABNORMAL
SLEEP or
impairment of
sport, leisure,
work or
troublesome
symptoms
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
Be mindful of
 Unilateral nasal discharge
 Purulent / bloody
 Foreign body until proven otherwise
 Clear / straw colored
 CSF leak until proven otherwise
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
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
AR - Investigations
 Skin Prick (epicutaneous)
 RAST
 nasal provocation test
 total IgE
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
Management
Hayfever = asthma of the nose
Patients need to appreciate this concept
AR - management
1. Allergen avoidance
2. Pharmacotherapy
3. Immunotherapy
4. Surgery
Multimodality treatment
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The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)
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
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
Allergen avoidance
 Animal dander
 Removal of animal from home
 If removal is not an option:
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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
Allergen avoidance
 Indoor mold
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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 ?
Minimize allergen load
 Regular nasal irrigation
 Normal saline irrigation
 Aim to physically wash out allergens
 May improve drug delivery
 May improve mucociliary clearance
Drugs
 Inhaled Nasal Corticosteroids
 Antihistamines - topical and systemic
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Anticholinergic sprays
Leukotrienes Inhibitors
Alpha-adrenergic agonists - decongestants
Mast-cell stabilizer
 Systemic and Intraturbinal Corticosteroid injections
Drugs
 Preventers
 Inhaled Nasal Corticosteroids
 Mast-cell stabilizer
 Leukotrienes Inhibitors
 Relievers
 Antihistamines - topical and systemic
 Anticholinergic sprays
 Emergency
 Systemic Corticosteroids
Drug treatment
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%
Antihistamines - oral
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Compete with Histamine for the H1 receptor.
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also change the three dimensional configuration of the receptor, decreasing its affinity
for histamine and down-regulating histamine-driven symptoms
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Most effective when taken prophylactically
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Non lipophilic second generation - do not cross the blood-brain barrier = minimal
sedative effects.
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Different classes may be more effective between differing individuals.
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Most effective at reducing symptoms of sneezing, nasal itching, and
rhinorrhea.
Antihistamines - topical
 Levocabastine (Livositin)
 Azelastine (Azep)
 RAPID onset
 Symptomatic relief
 DIAGNOSTIC in my practice
 Occular preparations
 Livsotin / Azep
 Patanol - antihistamine + mast cell stabilizer
Other Management Options
 Surgery
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Turbinoplasty
Vidian neurectomy
Posterior neurectomy
Septoplasty
FESS
 Immunotherapy
 Subcutaneous
 Sublingual
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)
SCIT
 Subcutaneous injections
 Weekly to monthly for 2-3 yrs
 Adverse effects
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Injection-site reactions
Sneezing
Bronchospasms
Urticaria
Anaphylaxis
 Contraindicated
 Severe or ustable asthma or pts on Beta blockers
SLIT
 Self daily administration
 Relatively expensive
 Limited but improving evidence
 Probably longer to work 3-5yrs
 SAFER
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The Unified Airway: concepts and management: Richard J. Harvey, Janet Rimmer, (in Press)

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