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Nasal Allergy and Allied Conditions

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Dr Asmatullah Achakzai
Dr Asmatullah Achakzai

Chronic allergic rhinitis is an IgE-mediated immunological response of the nasal mucosa to allergens. It can be seasonal or perennial. Clinical features include sneezing, nasal obstruction, rhinorrhea, and eye irritation. Diagnosis involves blood tests, nasal smears, and allergy tests. Treatment focuses on avoiding allergens, using medications like antihistamines and steroids, and surgery for severe cases. Non-allergic rhinitis includes vasomotor rhinitis caused by autonomic nervous system imbalances and rhinitis from other causes like medications, pregnancy, or endocrine disorders.

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Nasal Allergy and Allied Conditions
Dr Asmatullah Achakzai Associate Professor ENT Head and neck surgery FCPS, MCPS, DLO, MBBS Nasal Allergy and Allied Conditions
CHRONIC ALLERGIC RHINITIS What is Allergy? It was Clemens Von Pirquet, a Viennese pediatrician, who used the term allergy in 1906 denoting an altered state of reactivity to an organic substance, i.e. allergen. It is an immunoglobulin E (IgE)-mediated immunological response of nasal mucosa. Atopy means a tendency to develop allergic diseases.
Types of Allergic Response Type I or atopic hypersensitivity: Atopic hypersensitivity occurs in those persons who form reaginic antibodies when exposed to certain antigens. It is mediated by IgE antibodies, levels of which increase to more than 100 units/mL. This type of reaction is seen in allergic rhinitis, bronchial asthma, hay fever and eczema. Anaphylactic reaction: Anaphylactic reaction is a severe form of allergic reaction, which occurs immediately after exposure to the antigen, e.g. injecting horse serum and it can be fatal. Delayed hypersensitivity (Type IV): Unlike the above two types, it does not depend upon antibodies, but on sensitized T- lymphocytes.
Classification Allergic rhinitis and its impact on asthma (ARIA) panel in association with World Health Organization (WHO) recommended a revised classification in 2001, which aims at better management of allergic patients. It classifies it into: Mild Moderate to severe Intermediate Persistent type
Mechanism of Allergy (Pathogenesis) The mechanism of allergy (pathogenesis) are as follows: Reaginic antibodies also called IgE combine with cells such as circulating basophils or tissue mast cells. Later on, whenever there is provocation allergens combine with cell bound reaginic antibodies.
Predisposing Factors Following factors predispose the tissues to allergy Heredity Infection Endocrine Factors Nutritional Factors Geographical Factors PH Trauma Meteorological and Seasonal Conditions Psychological Factors
Types of Nasal Allergy Seasonal Allergic Rhinitis (Hay Fever) Hay fever is season specific because of prevalence of pollens of grasses, flowers, trees or shrubs. It starts in March to May or August to September. It may affect the nasal, pharyngeal or bronchial mucous membrane. Perennial Allergic Rhinitis Perennial allergic rhinitis is due to exogenous allergens such as inhalants, i.e. house dust, mattress, furniture, soaps, creams, perfumes, odors of fish, egg and coffee. House dust contains feces of mites Dermatophagoides pteronyssinus.
Clinical Features of Nasal Allergy Symptoms Irritation and itching of eyes and palate . Sneezing, 10 to 15 at a time . Nasal obstruction . Rhinorrhea . Increased lacrimation . Decreased or loss of sense of smell . Signs Chronic cough . Impairment of hearing . Congestion and edema of mucous membrane . Color of mucous membrane over turbinates may from pale to bluish or dull red . Mucous membrane becomes very sensitive and touching may initiate sneezing and rhinorrhea. Conjunctival congestion .
Investigations Blood for total leukocyte count (TLC) or differential leukocyte count (DLC) Nasal smear for eosinophils X-ray paranasal sinus (PNS) Special tests for allergy - Diagnostic nasal endoscopy - Saccharin test to test nasociliary function of nasal mucosa (normal duration is 30 minute).
Nasal Provocation Test Application of allergens to skin, nasal mucous membrane, bronchial mucous membrane or conjunctiva by simple application or scratch test (prick test). Intra cutaneous or intra mucosal injection, scratch or prick test are more specific and safer for inhalants, but intra dermai method is 100 times more sensitive than prick test.
Elimination of Allergies Such as foods likely to cause allergy or allergen free chamber may be used to see the effect. Leukopenic Index A drop of 2,000 in white blood cell (VVBC)/ml after ingestion of allergens indicates hypersensitivity. Radioallergosorbent Test Radioallergosorbent test (RAST) measures IgE level. It uses an enzymes instead of iostopes to label anti-IgG, which is measured in spectrometery.
Treatment Treatment can be discussed under the following subheads Avoiding the possibly known factor of allergy If the patient can find out the causative agent and avoids the contact, which may be any food article, any pet or other agent. It might need a change of job or place. Use of nasal filters or dust masks may help to some extent.
Role of Drugs Antihistamines Sympathomimetic drugs Role of steroids Topical nasal Sprays Submucosal corticosteroids and steroid depot therapy Sodium chromoglycate nasal spray
Non-Allergic Rhinitis Vasomotor rhinitis Rhinitis medicamentosa Endocrinal rhinitis: Drug-induced rhinitis such as contraceptive pills, antihypertensive and neostigmine.
Vasomotor Rhinitis Vasomotor rhinitis occurs more in emotionally unstable persons, especially in women of 20 to 40 years. It is because of over activity of para sysmpathesis due to imbalance of autonomic nervous systems (ANS) which is under the effects of hypothalamus.
Factors which disturb vasomotor balance Psychogenic factors Endocrine factors Physical agents Drugs
Pathology Nasal mucosa shows evidence of edema, vascular dilatation, round cell infiltration and increased glandular activity. Clinical Features Nasal obstruction and rhinorrhea are more pronounced than sneezing. Conjunctival symptoms not present Other symptoms such as postnasal drip, headache, fatigue and migraine, may be seen.
On Examination Enlargement or hypertrophy of turbinates Mucosa of turbinate may give mulberry-like appearance and is pale to dusky red in color treatment. Conservative treatment Physical exercise, cool baths and avoiding those factors, which initiate the symptoms. Tranquilizers such as alprazolam may also help Phenylpropanolamine 25 to 50 mg/day alone or in combination with antihistamines.
Surgical Treatment Cauterisation of turbinates helps in reduction of size Submucosal diathermy of the turbinates Cryosurgery is also helpful Vidian neurectomy
Other forms of Rhinitis There may be Rhinits of pregnancy. Drug induced rhinitis. Honeymoon rhinits. Endocrinal disorders as seen in hypothyroidism, Gustatory rhinitis as after a spicy food.
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Nasal Allergy and Allied Conditions

  • 2. Dr Asmatullah Achakzai Associate Professor ENT Head and neck surgery FCPS, MCPS, DLO, MBBS Nasal Allergy and Allied Conditions
  • 3. CHRONIC ALLERGIC RHINITIS What is Allergy? It was Clemens Von Pirquet, a Viennese pediatrician, who used the term allergy in 1906 denoting an altered state of reactivity to an organic substance, i.e. allergen. It is an immunoglobulin E (IgE)-mediated immunological response of nasal mucosa. Atopy means a tendency to develop allergic diseases.
  • 4. Types of Allergic Response Type I or atopic hypersensitivity: Atopic hypersensitivity occurs in those persons who form reaginic antibodies when exposed to certain antigens. It is mediated by IgE antibodies, levels of which increase to more than 100 units/mL. This type of reaction is seen in allergic rhinitis, bronchial asthma, hay fever and eczema. Anaphylactic reaction: Anaphylactic reaction is a severe form of allergic reaction, which occurs immediately after exposure to the antigen, e.g. injecting horse serum and it can be fatal. Delayed hypersensitivity (Type IV): Unlike the above two types, it does not depend upon antibodies, but on sensitized T- lymphocytes.
  • 5. Classification Allergic rhinitis and its impact on asthma (ARIA) panel in association with World Health Organization (WHO) recommended a revised classification in 2001, which aims at better management of allergic patients. It classifies it into: Mild Moderate to severe Intermediate Persistent type
  • 6. Mechanism of Allergy (Pathogenesis) The mechanism of allergy (pathogenesis) are as follows: Reaginic antibodies also called IgE combine with cells such as circulating basophils or tissue mast cells. Later on, whenever there is provocation allergens combine with cell bound reaginic antibodies.
  • 7. Predisposing Factors Following factors predispose the tissues to allergy Heredity Infection Endocrine Factors Nutritional Factors Geographical Factors PH Trauma Meteorological and Seasonal Conditions Psychological Factors
  • 8. Types of Nasal Allergy Seasonal Allergic Rhinitis (Hay Fever) Hay fever is season specific because of prevalence of pollens of grasses, flowers, trees or shrubs. It starts in March to May or August to September. It may affect the nasal, pharyngeal or bronchial mucous membrane. Perennial Allergic Rhinitis Perennial allergic rhinitis is due to exogenous allergens such as inhalants, i.e. house dust, mattress, furniture, soaps, creams, perfumes, odors of fish, egg and coffee. House dust contains feces of mites Dermatophagoides pteronyssinus.
  • 9. Clinical Features of Nasal Allergy Symptoms Irritation and itching of eyes and palate . Sneezing, 10 to 15 at a time . Nasal obstruction . Rhinorrhea . Increased lacrimation . Decreased or loss of sense of smell . Signs Chronic cough . Impairment of hearing . Congestion and edema of mucous membrane . Color of mucous membrane over turbinates may from pale to bluish or dull red . Mucous membrane becomes very sensitive and touching may initiate sneezing and rhinorrhea. Conjunctival congestion .
  • 10. Investigations Blood for total leukocyte count (TLC) or differential leukocyte count (DLC) Nasal smear for eosinophils X-ray paranasal sinus (PNS) Special tests for allergy - Diagnostic nasal endoscopy - Saccharin test to test nasociliary function of nasal mucosa (normal duration is 30 minute).
  • 11. Nasal Provocation Test Application of allergens to skin, nasal mucous membrane, bronchial mucous membrane or conjunctiva by simple application or scratch test (prick test). Intra cutaneous or intra mucosal injection, scratch or prick test are more specific and safer for inhalants, but intra dermai method is 100 times more sensitive than prick test.
  • 12. Elimination of Allergies Such as foods likely to cause allergy or allergen free chamber may be used to see the effect. Leukopenic Index A drop of 2,000 in white blood cell (VVBC)/ml after ingestion of allergens indicates hypersensitivity. Radioallergosorbent Test Radioallergosorbent test (RAST) measures IgE level. It uses an enzymes instead of iostopes to label anti-IgG, which is measured in spectrometery.
  • 13. Treatment Treatment can be discussed under the following subheads Avoiding the possibly known factor of allergy If the patient can find out the causative agent and avoids the contact, which may be any food article, any pet or other agent. It might need a change of job or place. Use of nasal filters or dust masks may help to some extent.
  • 14. Role of Drugs Antihistamines Sympathomimetic drugs Role of steroids Topical nasal Sprays Submucosal corticosteroids and steroid depot therapy Sodium chromoglycate nasal spray
  • 15. Non-Allergic Rhinitis Vasomotor rhinitis Rhinitis medicamentosa Endocrinal rhinitis: Drug-induced rhinitis such as contraceptive pills, antihypertensive and neostigmine.
  • 16. Vasomotor Rhinitis Vasomotor rhinitis occurs more in emotionally unstable persons, especially in women of 20 to 40 years. It is because of over activity of para sysmpathesis due to imbalance of autonomic nervous systems (ANS) which is under the effects of hypothalamus.
  • 17. Factors which disturb vasomotor balance Psychogenic factors Endocrine factors Physical agents Drugs
  • 18. Pathology Nasal mucosa shows evidence of edema, vascular dilatation, round cell infiltration and increased glandular activity. Clinical Features Nasal obstruction and rhinorrhea are more pronounced than sneezing. Conjunctival symptoms not present Other symptoms such as postnasal drip, headache, fatigue and migraine, may be seen.
  • 19. On Examination Enlargement or hypertrophy of turbinates Mucosa of turbinate may give mulberry-like appearance and is pale to dusky red in color treatment. Conservative treatment Physical exercise, cool baths and avoiding those factors, which initiate the symptoms. Tranquilizers such as alprazolam may also help Phenylpropanolamine 25 to 50 mg/day alone or in combination with antihistamines.
  • 20. Surgical Treatment Cauterisation of turbinates helps in reduction of size Submucosal diathermy of the turbinates Cryosurgery is also helpful Vidian neurectomy
  • 21. Other forms of Rhinitis There may be Rhinits of pregnancy. Drug induced rhinitis. Honeymoon rhinits. Endocrinal disorders as seen in hypothyroidism, Gustatory rhinitis as after a spicy food.