3/18/2016

Allergic vs Non‐Allergic ROBIE GRAY PA‐C UNIVERSITY OF COLORADO SINUS CENTER RHINOLOGY ENT FOR THE PA‐C CONFERENCE MARCH 2016

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Allergic vs Non‐

Objectives: • Identify history of allergic vs non‐allergic rhinitis • Recognize clinical and laboratory findings that facilitate differentiation • Current guidelines for treatment

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Allergic vs Non‐Allergic Rhinitis

• No Disclosures

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Allergic vs Non‐Allergic Rhinitis

• Clinical Practice Guidelines: Allergic Rhinitis

American Academy of Otolaryngology‐Head and Surgery 2015, Vol. 152(IS)S1‐S43

• The Diagnosis and Management of Rhinitis: An Updated Practice Parameter

Joint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐84

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

What is Rhinitis?

One or more of the following: • Congestion • anterior or posterior • Sneezing and Pruritus

Typically associated with inflammation though some forms of rhinitis are not

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Associated Conditions

• Allergy • • Sino‐pulmonary issues • Aspirin sensitivity • Less common – – Immunodeficiencies – Autoimmune conditions

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Rhinitis Morbidity

• Quality of life: fatigue, headaches, sleep disturbances, and cognitive impairment • Complicating respiratory conditions • Reduced work/school • Direct and indirect costs in the U.S. of 11 billion dollars according to the Joint Task Force on Practice Parameters

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Allergic Rhinitis

IgE mediated reactions to environmental triggers following sensitization • Perennial • Seasonal • Episodic

Characterized by frequency and severity • Intermittent • Persistent • Mild • More severe

Allergic Rhinitis: cardinal symptoms

Rhinorrhea Congestion

Pruritus Sneezing

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Allergic Rhinitis Physical Exam Findings

Nasal Crease Allergic Shiner

Atopic Dermatitis Wheezing

Allergic Rhinitis: nasal exam

Allergic Rhinitis Diagnostics

Allergy Testing Recommendations • Should perform and interpret or refer to a clinician who can: specific IgE skin or blood testing for those not responding to empiric treatment; or diagnosis is uncertain; or targeted therapy is desired.

American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43

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Allergic Rhinitis Diagnostics

• Skin Testing: preferred method to confirm an IgE‐mediated response taking advantage of reactions • Skin prick, Intradermal, and Intradermal dilution (known in the past as serial dilution or skin endpoint titration) • RAST: radioallergosorbent

Skin Prick Testing

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Intradermal Testing

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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RAST Radioallergosorbent Test • Measurement of total serum IgE and IgE levels against allergy antigens • Benefits: no risk for allergic reaction; results not effected by medications or skin conditions; no need for extensive testing materials or rescue medications • Caution: inappropriate use of this screening test in unselected populations may produce positive results in asymptomatic patients as IgE antibody responses are more frequent than symptomatic disease

Allergic Rhinitis Co‐Morbidities

• Asthma

• Atopic dermatitis

• Sleep disordered breathing

• Rhinosinusitis

• Otitis American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43

Allergic Rhinitis Treatments

Strong Recommendations • Intranasal steroids • PO second generation/less sedating antihistamines Recommendations Against • Routine sinonasal imaging • PO leukotriene receptor antagonist as primary therapy American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43

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Allergic Rhinitis Treatments

Recommendations • Immunotherapy SCIT or SLIT • Duration of Allergy Immunotherapy 3‐5 years if there is a beneficial response • Allergy Immunotherapy is not always a cure but does relieve symptoms in up to 80% of patients • Newer FDA approved sublingual tablets for seasonal use: grass and ragweed

Allergic Rhinitis Treatments

Options • Environmental controls • Intranasal antihistamines • Combo therapy • Surgical referral • Acupuncture

American Academy of Otolaryngology‐Head and Neck Surgery 2015, Vol. 152(IS)S1‐S43

LaForce CF, Corren J, Wheeler WJ, et al. Efficacy of Azelastine in SAR patients who remain symptomatic after treatment with Fexofenadine. Ann Allergy Asthma Immunol. 2004;93:154‐159

Allergic Rhinitis Treatments

Recommendations • Intranasal Cromolyn effective in some patients with minimal side effects

• Nasal Saline is beneficial • Oral Decongestants can reduce but have significant side effects • Omalizumab demonstrates effectiveness but only indicated for allergic asthma and chronic urticaria

The Diagnosis and Management of Rhinitis: An Updated Practice Parameter

Joint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐84

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Allergic Rhinitis Treatments

• Oral Corticosteroids: short courses for severe nasal symptoms OK

• Parenteral single dose is discouraged and recurrent administrations are contraindicated

Joint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐84

Special Considerations in AR Treatments • Second and First Generation Antihistamines • Cromolyn • Montelukast • Intranasal Corticosteroids • AI Continuation

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Non‐Allergic Rhinitis

• Vasomotor • Foods and ETOH • Infectious • NARES • Occupational • Hormonal • Drug‐induced • Atrophic

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Vasomotor Rhinitis “idiopathic rhinitis” • Rhinorrhea: think cholinergic secretory activity

• Gustatory: think vagally mediated

• Nasal congestion: think heightened nociceptive neuron sensitivity

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Infectious: Rhinosinusitis

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

NARES Non‐Allergic Rhinitis with Eosinophilia Syndrome

• Paroxysmal sneezing, profuse watery rhinorrhea, nasal pruritus, congestion, and anosmia

• Middle aged

• 5‐20% Eosinophils on smear

• Develop nasal polyposis and AERD

Settipane GA, Klein DE, Non allergice rhinitis: demography of eosinophils in nasal smear, blood total eosinophil counts and IgE levels. N Eng Reg Allergy Proc 1985:6:363‐6

Moneret‐Vautrin DA, Hsieh V, Wayoff M, Guyot JL, Mouton C, Maria Y. with eosinophilia syndrome a precursor of the triad: nasal polyposis, inrinsic asthma, and intolerance to ASA. ANN Allergy 1990;64:513‐8

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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NARES Non‐Allergic Rhinitis with Eosinophilia Syndrome Wrights Stain Distilled Water

5‐20% Eosinophils on smear

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Hormonal

Pregnancy • Nasal vascular pooling, vascular dilation, and increasing blood volumes • Starts before 6 weeks and ends 2 weeks post‐ delivery Ovulation • Associated with the rise in estrogen

Joint Task Force on Practice Parameters, AAAAI, ACAAI, Joint Council of AAI J Allergy Clinical Immunology 2008;122:S1‐ 84

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Drug induced

• ACEI

• Phosphodiesterase 5 selective inhibitors

• Phentolamine

• Alpha receptor antagonists

• ASA/NSAID

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Drug Induced Rhinitis Medicamentosa Intranasal alpha‐adrenergic decongestants

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Atrophic Rhinitis

Primary Secondary • Developing countries with • Chronic granulomatous warm climates disorders • Progressive atrophy of the • Chronic glandular cells • Excessive surgery to • Crusting, dryness, fetor turbinates • Klebsiella ozaenae, S • Irradiation aureus, Proteus mirabilis and E coli Zohar Y, Talmi YP, Strauss M, et all. Ozena revisited. J Otolaryngol 1990;19:345‐9

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Atrophic Rhinitis

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Non‐Allergic Rhinitis Treatments

• Intranasal corticosteroids

• Intranasal antihistamines

• Intranasal anticholinergic

• Intranasal capsaicin: nociceptors

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Non‐Allergic Rhinitis Treatments

• Stop or change causative medication

• Oral or topical decongestants short term

• Nasal Hygiene

• PO ABRS or topical antibiotics (think Atrophic)

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Rhinitis: When to Look Deeper

• Failure or non‐response to empiric treatment

• Anosmia

• Nasal obstruction

• Epistaxis

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Endoscopes

• Pictures courtesy Todd Kingdom, MD CU Sinus Center

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Normal Chronic Sinusitis

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Rhinitis: Special Circumstances

• Nasal polyps • AERD • CRS • CSF rhinorrhea • Ciliary dysfunctions • Nasal mass ‐ benign and malignant

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Rhinitis‐Special Circumstances

Inflammatory‐Immunologic Disorders • Granulomatosis with polyangiitis GPA/Wegener's • • Midline granuloma • Churg‐Strauss • Relapsing polychondritis • Amyloidosis • Granulomatous infections

Nasal Polyps/AERD

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Nasal Polyps/AERD

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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CRS‐Chronic Rhinosinusitis

Case: Ms. S • Ms. S intermittent rhinorrhea • No response to topical or oral medications • Negative allergy testing • H/O Cluster headaches • PMH 3 transsphenoidal pituitary procedures most recent –5 years ago.

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Case: Ms. S

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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How Do We Know If Someone Has A CSF Leak?

Ciliary Dyskinesia

• Primary associated with and 50% of the time with situs inversus/Kartagener syndrome

• Secondary causes include CRS, ARS, multiple sinus procedures, or irritant rhinitis (smoking).

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

PCD‐Primary Ciliary Dyskinesia

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Inverted Papilloma

Malignant

Rhinitis ANATOMY AND SURGICAL OPTIONS

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Nasal Obstruction

Picture courtesy Todd Kingdom CU Sinus Center

Surgical Options Nasal obstruction

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Turbinates

Picture Courtesy Todd Kingdom MD, CU Sinus Center

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Nasal Obstruction Surgery: Inferior Turbinate Hypertrophy

Picture Courtesy Todd Kingdom MD, CU Sinus Center

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Nasal Obstruction Surgery: Inferior Turbinate Reduction

Picture Courtesy Todd Kingdom MD, CU Sinus Center

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Septoplasty

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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Vidian Neurectomy

• Intractable non‐allergic rhinitis • Favorable anatomy: floor of the sphenoid sinus • Reported as 50‐90% patients noting improvement • Side effects dry eye and nasal crusting

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Thank You!

Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

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