Rhinitis

1
Rhinitis

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

2
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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?catID29
  itemID158. 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 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

11
Allergic Rhinitis

• 50 patients symptomatic gt 4 months/year
• 20 patients symptomatic gt 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

• 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/PxgtgtgtgtLabgtgtgtgtDxgtgtgtgtRx
• Rhinitis
• Hx/PxgtgtgtgtDxgtgtgtgtRx
• 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 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

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
Quality-of-Life Issues

• Fatigue
• Concentration
• Nuisance
• Sleep disturbance
• Emotional well being
• Social interactions

• Missing school/work
• Halitosis
• Decreased daily production
• Impaired studying
• Sniffing/snorting
• Blowing nose

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 lt0.005 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
200030891.
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. 2002285-88. Bousqu
et J. et al. J Allergy Clin Immunol.
2001108S147-S333. Marone et al. Int Arch
Allergy Immunol. 2001124249-52.
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. 2002285-88 Bousque
t J. et al. J Allergy Clin Immunol.
2001108S147-S333 Marshall GD. JACI.
2000106S303-309
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.
2001108S147-S333 De Paulis A. et al.
(Abstract). Allergy. 199954 (suppl
52)278 Lindstedt KA. et al. J Lipid Res.
19923365-75 Marshall GD. JACI. 2000106S303-309
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. 199881478-518.
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 lt 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 gt 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
Causes of Rhinitis

• Irritants
• Adverse food reaction
• Emotional
• Atrophic
• Ciliary dyskinesia
• Immunodeficiency diseases

• Allergy
• NARES syndrome
• Occupational
• Hormonal
• Drug induced
• Anatomic defects

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, Dennies
  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
• Wrights or Hansels 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
• 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
• 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

51
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

52
General Treatment Modalities

• Vigorous exercise
• Posture
• Avoidance procedures
• Saline irrigation

53
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

54
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

55
Treatment of Mild Allergic Rhinitis Occasional
exposure/symptoms Step 1

• Environmental control
• Saline irrigation
• Monotherapy
• Nasal steroid or
• Nonsedating antihistamine or
• Astelazine nasal spray

56
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

57
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

58
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

59
Environmental Control

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

60
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

61
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

62
Pharmacotherapy

• Allergic rhinitis
• Antihistamines
• OTC
• Nonsedating
• Nasal steroids
• Nasal cromolyn
• Astelazine nasal spray
• Decongestants

• Nonallergic rhinitis
• Antihistamines
• Drying effect
• Decongestants
• Astelazine
• Ipatropium
• Nasal steroids
• NARES syndrome

63
Nasal Steroids

• Flonase
• Beconase
• Nasonex
• Nasacort
• Rhinocort
• Vancenase
• Tri-Nasal

64
Nonsteroid Nasal Sprays

• Astelazine
• Atrovent
• Nasalcrom
• Saline

65
Comparison of Various Approaches to the
Treatment of Allergic Rhinitis
Sneezing Discharge Itch Congestion Side
effects Antihistaminestraditional
(A) Nonsedating(NSA)
to Azelastine to
Decongestants NSA
decongestants Leukotriene
antag. to to to to
Cromolyn Nasal CCS
(NCS) NSA NCS
Immunotherapy to
Presumed no data on individual symptoms
Nayak AS, et al. Ann Allergy Asthma Immunol.
200288592-600. Strongly positive
effect Minimal effect
66
Nonallergic Rhinitis

• As important as allergic rhinitis
• Present in 57 of patients with rhinitis

67
Nonallergic/Vasomotor Rhinitis

• Perennial or episodic symptoms
• Chronic, nonpruritic rhinorrhea/congestion
• Negative nasal eosinophils
• Negative allergy screening
• Nonallergic excitants
• Viruses
• Chemicals, tobacco smoke, potpourri
• Nonallergic foods
• Weather changes

68
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

69
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

70
Treatment of Nonallergic Rhinitis

• Astelazine nasal spray
• Steroid nasal spray
• Nasal irrigation
• Avoidance
• Effectiveness of antihistamines questionable

71
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?

72
Rhinitis Case Study

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

73
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

74
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
  

75
Medications That May Cause Rhinitis

• Aldomet
• Cardura
• Catapres
• Corgard
• Hytrin
• Ismelin

• Minipres
• Moduretic
• Normodyne
• Trandate
• Viagra
• Wytensin

76
Hormonal Causes of Rhinitis

• Pregnancy
• Second month to term
• Puberty
• Oral contraceptives
• Hypothyroid state

77
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

78
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

79
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?

80
NARES Syndrome

• Nasal smear revealed marked eosinophilia
• Diagnosis NARES syndrome nonallergic rhinitis
  with eosinophilia

81
NARES Syndrome

• Perennial symptoms
• Sneezing
• Rhinorrhea
• Pruritis
• Occasional loss of smell
• Nasal smear positive for eosinophils
• Allergy screen is negative

82
Nasal Mastocytosis is Rare

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

83
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.
  
• Diagnosis?

84
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

85
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

86
Treatment of Atrophic Rhinitis

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

87
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?

88
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?

89
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

90
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

91
Common Workplaces for Occupational Rhinitis

• Beauty salons
• Clothing stores
• Supermarkets
• Auto body spraying
• Service stations
• Woodworking
• Pesticide industry
• Plastic manufacturing

• Tanneries
• Paper industry
• Gardening products
• Insecticides
• Food industry
• Laboratory animals
• Office machinery
• Paints, chemicals

92
Common Chemical Exposures Causing Rhinitis

• 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

93
Mechanical Causes of Rhinitis

• Deviated nasal septum
• Nasal polyps
• Foreign body
• Tumors of the nose
• Congenital atresia

• Meningocoele
• Adenoid hypertrophy
• Variants of the osteomeatal complex
• Concha bullosa

94
Gustatory Rhinitis

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

95
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

96
Vasculitides, Autoimmune and Granulomatous Causes

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

97
Pharmacotherapy

• Allergic rhinitis
• Antihistamines
• OTC
• Nonsedating
• Nasal steroids
• Nasal cromolyn
• Astelazine nasal spray
• Decongestants

• Nonallergic rhinitis
• Antihistamines
• Drying effect
• Decongestants
• Astelazine
• Ipatropium
• Nasal steroids
• NARES syndrome

98
Treatment of Bacterial Rhinitis

• Antibiotics
• Ointment
• Systemic
• Saline sprays

99
Treatment of Atrophic Rhinitis

• Saline irrigation
• Ipatropium

100
Nasal Polyps

• Grape-like clusters
• Maxillary sinus
• Inflammatory process
• One third associated with asthma
• Asthma-aspirin-polyp triad
• High rate of recurrence

101
Nasal Polyps

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

102
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

103
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

104
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

105
Refer to an Allergist

• Hymenoptera sensitivities
• Antibiotic desensitization
• Anesthetic testing
• Patients with history of anaphylaxis
• Medication
• Shellfish
• Peanut or other food reactions

106
Allergy Testing and Allergy Screening in Family
Practice

• A very cost effective procedure to learn

107
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

108
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

109
Skin Testing Disadvantages

• Affected by medications
• Antihistamines
• Steroids
• Patient discomfort
• Rare possibility of anaphylaxis
• Dermagraphism
• Chronic skin disorders
• Very young and atrophic skin

110
Puncture/Prick Testing
Figure 1

• Disease-free site
• Swipe with alcohol
• Apply drop of antigen (110 or 120 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

Example of a skin prick/puncture epicutaneous
test
111
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

112
Multiple Antigen Testing contd
Figure 2
Figure 3
Example of multiple-puncture device in its
loading dock
Example of multiple-puncture device allowing
simultaneous placement of six allergens plus a
positive and negative control
113
Multiple Antigen Testing contd
Figure 4
Figure 5
Example of positive and negative skin responses
to allergens applied with a multiple-puncture
device note the positive and negative control
sites
Example of application of a multiple-puncture
device to the forearm
114
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

115
Grading of MultiTest

• 0 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 gt10 mm wheal
• 5 Erythema with gt10 mm wheal and pseudopods
  

116
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

117
Positive and Negative Controls

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

118
In-Vitro Testing

• Reference laboratory
• Many available
• In-office labs
• Weigh expense involved

119
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

120
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

121
RAST Scoring

• 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

122
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

123
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

124
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

125
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

126
Allergy Screening

• A most cost effective test to do!

127
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

128
References

• Nalebuff, DJ. Use of RAST screening in clinical
  allergy a cost-effective approach to patient
  care. Ear Nose Throat J. 1985 64107-21.
• Blok et al. Reported use of 5 antigen screens.
  Allergy. 1991

129
Screening Allergens-Most Common from Geographic
Area

• Negative control
• Weed (ragweed)
• Grass (June)
• Tree (oak or elm)

• Positive control
• House dust mites
• Mold (alternaria)
• Cat

130
Typical Midwest Screen

• Ragweed
• House dust mite
• Cat
• June grass
• Oak tree
• Alternaria

131
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?complete
  allergy panel
• House dust mite only positive?avoidance
• Cat only positive?avoidance

132
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

133
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

134
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.
  199371485-91
• Foods if indicated

135
Cross-Reacting Pollens

• June rye, sweet vernal, timothy, brome, red top
• Oak tree species
• Hickory and pecan trees
• Ragweed species

136
Before Considering Immunotherapy

• Always correlate history with test results.

137
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

138
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

139
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.

140
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.

141
Allergy Resources Available to Family Physicians

• American Academy of Family Physicians
  1-800-274-2237
• Antigen Laboratories1-816-781-5222
• Allergy Laboratories 1-800-654-3971
• National Procedures Institute
  1-800-462-2492
• Pan American Allergy Society1-210-997-9853

142
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?catID29
  itemID158. Accessed August 2003.

143
Thank You
This has been a presentation of the American
Academy of Family Physicians