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Allergic Vs Non-Allergic Rhinitis Allergic Vs Non-Allergic Rhinitis

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Allergic Vs Non-Allergic Rhinitis Allergic Vs Non-Allergic Rhinitis 3/18/2016 Allergic vs Non‐Allergic Rhinitis 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‐Allergic Rhinitis 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 1 3/18/2016 Allergic vs Non‐Allergic Rhinitis • Clinical Practice Guidelines: Allergic Rhinitis American Academy of Otolaryngology‐Head and Neck 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 • Rhinorrhea 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 • Asthma • Sino‐pulmonary issues • Aspirin sensitivity • Less common – Cystic Fibrosis – Immunodeficiencies – Autoimmune conditions 2 3/18/2016 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 3 3/18/2016 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 4 3/18/2016 Allergic Rhinitis Diagnostics • Skin Testing: preferred method to confirm an IgE‐mediated response taking advantage of type I hypersensitivity 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 5 3/18/2016 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 6 3/18/2016 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 nasal spray 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 nasal congestion 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 7 3/18/2016 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 Pregnancy • 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 8 3/18/2016 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. Nonallergic rhinitis 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 9 3/18/2016 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 10 3/18/2016 Drug Induced Rhinitis Medicamentosa Intranasal alpha‐adrenergic Cocaine 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 sinusitis 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 11 3/18/2016 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 12 3/18/2016 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
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