Otolaryngology Book

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Allergic RhinitisAka: Hayfever, Allergic Shiner, Dennie's Lines, Allergic Salute

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  1. Epidemiology
    1. Onset under age 30
    2. Peak Incidence in childhood and adolescence
    3. Most common chronic disease in United States
      1. Affects 35 million Americans
      2. Accounts for two million missed school days
      3. Accounts for three million missed work days
    4. Significantly affects quality of life
  2. Pathophysiology
    1. Type I Antibody-Antigen reaction to allergens
    2. May take 4 years in a given region to be sensitized
    3. Sequence of events
      1. T Lymphocytes and B Lymphocytes release IgE Antibody
      2. Mast Cells in skin and mucosa with second exposure
      3. Mast Cells degranulate
      4. Release of histamine and chemotactic factors
        1. Release of Prostaglandins and Leukotrienes
        2. Response of Intravascular Basophils
        3. Late phase reactants release histamine over 12 hour
  3. Associated Conditions
    1. Atopy
      1. Eczematous Dermatitis
      2. Allergic Rhinitis
      3. Asthma
    2. Allergic Triad
      1. Aspirin Allergy
      2. Nasal Polyps
      3. Asthma
  4. Family History
    1. Allergy
    2. Asthma
    3. Atopy
  5. History
    1. Atopy
    2. History of nasal trauma
    3. Medication use
      1. NSAIDs
      2. Antihypertensive Medications
      3. Oral Contraceptives
  6. Suspected environmental allergens
    1. Seasonal Allergens
      1. Tree pollen (early spring)
      2. Grass pollen (late spring)
      3. Outdoor Molds (summer and fall)
      4. Weed pollen (late summer to fall)
    2. Perennial
      1. Dust mites
      2. Animal dander
    3. Irritant
      1. Cigarette Smoke
  7. Symptoms: Specific
    1. Sneezing
    2. Rhinorrhea
    3. Nasal congestion
    4. Pruritus of the nose, eyes, and throat
    5. Eye Tearing and Conjunctival discharge
  8. Symptoms: Chronic Nasal Obstruction
    1. Mouth Breathing
    2. Snoring
    3. Anosmia
    4. Cough
    5. Headache
    6. Decreased Hearing
    7. Halitosis
  9. Symptoms: Generalized due to chronicity of Rhinitis
    1. Irritability
    2. Fatigue
    3. Depression
    4. Malaise
    5. Weakness
  10. Signs
    1. Vitals
      1. Rule out Hypertension associated with Antihistamines
    2. Nose
      1. Use Nasal speculum with high power illumination
      2. Examine before and after topical nasal Decongestant
      3. Mucosa
        1. Pale blue
        2. Boggy
        3. Clear discharge
    3. Ocular
      1. Palpebral Conjunctiva pale and swollen
      2. Bulbar Conjunctiva injected with clear discharge
    4. Face
      1. Allergic Shiners
        1. Bluish purple rings around both eyes
        2. Results from chronic mid-face venous congestion
      2. Dennie's Lines
        1. Skin folds under eyes
      3. Allergic salute
        1. Transverse nasal crease from chronic nose rubbing
    5. Mouth
      1. High arched narrow palate OR
      2. Malocclusion from chronic mouth breathing
      3. "Cobblestoning" of adenoids and tonsils
    6. Ear (Rule out associated Eustachian Tube Dysfunction)
      1. Dull, immobile Tympanic Membrane
      2. Conductive Hearing Loss
    7. Sinus (Rule out Sinusitis)
      1. Purulent discharge
      2. Tender
      3. Impaired transillumination
  11. Labs:
    1. Skin Testing
      1. Gold standard
    2. RadioAllergoSorbent Test (RAST Test)
      1. Use if unable to skin test contraindicated as above
    3. Nasal Smears
      1. Eosinophils supportive of a diagnosis
    4. Complete Blood Count
      1. Normal White Blood Cell count
      2. Increased Eosinophils
    5. IgE elevated
  12. Differential Diagnosis
    1. Nasal Causes of Rhinitis
      1. Nonallergic Rhinitis (Eosinophilia Syndrome)
      2. Nasal Polyps
      3. Vasomotor Rhinitis
      4. Infectious Rhinitis
      5. Rhinitis Medicamentosa
      6. Gustatory Rhinitis
        1. Spicy foods lead to tearing and sweating
    2. Miscellaneous Causes of Rhinitis
      1. Pregnancy
      2. Alcohol Abuse
      3. Cocaine abuse
      4. Hypothyroidism
        1. Results in nasal obstruction
    3. Medications associated with Rhinitis
      1. Aspirin
      2. Clonidine
      3. Guanabenz
      4. Guanethidine
      5. Hydralazine
      6. Labetalol
      7. Methyldopa
      8. Prazosin
      9. Oral Contraceptives
      10. Propranolol
      11. Reserpine
      12. Terazosin
  13. Management
    1. Decrease Environmental Allergens
    2. Intranasal Steroids
      1. Effectively controls Itching, sneezing and discharge
      2. Moderately controls blockage symptoms
      3. Small effect of impaired smell
    3. Antihistamine
      1. Effectively controls itching and sneezing symptoms
      2. Moderately controls discharge
    4. Saline Nasal Drops
    5. Ipratropium Bromide
      1. Effectively controls Nasal discharge
    6. Ocular Allergy Preparations
    7. Intranasal Cromolyn
      1. Small effect on symptoms
    8. Systemic steroids (severe cases)
    9. Hyposensitization
    10. Petrolatum
      1. Applied 4 times daily to inside of nares
      2. Reduces nasal allergic symptoms
      3. Schwetz (2004) Arch Otolaryngol Head Neck Surg :
  14. Resources
    1. Patient oriented allergy information
      1. http://www.gazoontite.com
    2. Information from your Family Doctor: General
      1. http://www.familydoctor.org/handouts/679.html
    3. Information from your Family Doctor: Symptom Control
      1. http://www.familydoctor.org/healthfacts/083/
    4. Information from your Family Doctor: Allergy Shots
      1. http://www.familydoctor.org/handouts/232.html

Allergic rhinitis NOS (C0002103)

ConceptsDisease or Syndrome (T047)
ICD9477, 477.9
EnglishAllergic rhinitis, Allergic rhinitis due to allergen, Allergic rhinosinusitis, ALRH, AR - Allergic rhinitis, Atopic rhinitis, Rhinitis - allergic, RHINITIS ALLERGIC
Spanishrinitis alergica, rinitis atopica
Parent ConceptsAllergic rhinitis NOS (C0002103), [X]Other diseases of the upper respiratory tract (C0155839), Rhinitis (C0035455), Allergic disorder of respiratory system (C1504369), Atopic IgE-mediated allergic disorder (C1706410)
SourcesCOSTAR, CST, DXP, ICD9CM, NCI, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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