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									Management of Rhinitis in
  Patients with Asthma

        Michael Schatz, MD, MS
     Chief, Department of Allergy
   Kaiser Permanente, San Diego, CA
Some Misconceptions About Rhinitis

 • Rhinitis is a trivial illness.
 • All rhinitis is allergic.
 • All non-allergic rhinitis is homogeneous.
            Outline of Presentation
   Practical classification of chronic rhinitis
   Diagnostic approach in primary care
   Specific syndromes
     Distinguishing features
     Treatment
              Practical Classification
   Allergic Rhinitis
     Seasonal versus Perennial
     Frequency
          Persistent (> 4 days/week for > 4 weeks/year)
          Intermittent (less than above)

       Severity
          Mild
          Moderate-severe (interference with sleep or daily activities
           or “troublesome symptoms”)
   Other
        Practical Classification: Other
   Other
     Rhinitis medicamentosa
     Septal deviation

     Eosinophilic non-allergic rhinitis

     Nasal polyps

     Cholinergic rhinitis

     Vasomotor rhinitis

     GERD induced “post nasal drip”

     Turbinate hypertrophy

     Chronic sinusitis
    Practical Classification: Asthmatic
                  Patient
   Other
     Rhinitis medicamentosa
     Septal deviation

     Eosinophilic non-allergic rhinitis

     Nasal polyps

     Cholinergic rhinitis

     Vasomotor rhinitis

     GERD induced “post nasal drip”

     Turbinate hypertrophy

     Chronic sinusitis
Chronic Rhinitis: Diagnostic Approach


    1. History
    2. Physical Exam
    3. Tests
    Chronic Rhinitis: Diagnostic Tests

   Nasal smear (eosinophilic disease)
   Specific IgE (allergic versus non-allergic)
     Skin tests
     RAST (blood tests)

   Total IgE (AFS)
   Immunoglobulins G, A, M
    (hypogammaglobulinemia with chronic sinusitis)
   Fungal precipitating antibody
   Sinus radiology
        Skin Tests versus Blood Tests
   Skin Tests
     Time-honored method
     Results immediately available
     More sensitive for some allergens or patients
     Potential for systemic reactions
     Antihistamines interfere

   Blood tests
     Easier for patient
     May be more specific
     No interference by medications or potential for systemic
      reactions
           Outline of Presentation
   Practical classification of chronic rhinitis
   Diagnostic approach in primary care
   Specific syndromes
     Distinguishing features
     Treatment
                     Allergic Rhinitis
   Distinguishing Features
     Sneezing, itching, rhinorrhea prominent
     May be seasonal

     Triggered by freshly cut grass, cleaning house, or pet
      exposure
   Treatment
     Indoor allergen avoidance
     Intermittent: Antihistamines, intranasal corticosteroids
      (INS) as needed
     Persistent: Regular INS; add antihistamines (oral and/or
      intranasal) and montelukast if needed)
     Consider immunotherapy
                Immunotherapy

   Consider for patients with definite allergic
    rhinitis not controlled by other means
   Because of potentially life-threatening allergic
    reaction, it should be carried out only by
    specialists trained in its use
   Goal: symptom and/or medication reduction,
    not usually eradication or cure
               Immunotherapy 2

   Used less for rhinitis now than it used to be due
    to better medications
   Less effectiveness data for mold and animal
    dander
   One year trial
   If effective, continue for 3-5 years and then
    consider discontinuation
   Sublingual immunotherapy (SLIT) now being
    studied
    Eosinophilic Non-Allergic Rhinitis
   Distinguishing features
     Prominent mucosal edema
     Nasal eosinophilia

     No relevant allergy

   Treatment
     Intranasal corticosteroids
     Oral antihistamine or antihistamine-decongestant
      combination if needed
     Oral prednisone for recalcitrant disease
                   Nasal Polyps
   Distinguishing Features
     Nasal obstruction
     Anosmia

     Nasal polyps on exam

   Treatment
     Intranasal corticosteroids
     Course of doxycycline (20 days)

     Oral corticosteroids

     Treatment of complicating infection

     Consider montelukast

     Surgery (polyp, sinus)
    GERD Induced “Post Nasal Drip”
   Distinguishing features
     Feeling of post-nasal drip or mucus in throat with
      minimal or no other nasal symptoms
     May be associated with hoarseness, throat clearing,
      cough, pyrosis, regurgitation
     May be worse after eating

   Treatment
     Reflux precautions
     Protein pump inhibitors
        Practical Classification: Other
   Other
     Rhinitis medicamentosa
     Septal deviation

     Eosinophilic non-allergic rhinitis

     Nasal polyps

     Cholinergic rhinitis

     Vasomotor rhinitis

     GERD induced “post nasal drip”

     Turbinate hypertrophy

     Chronic sinusitis
    Symptoms Suggestive of Chronic
              Sinusitis
   Nasal congestion
   Pain or pressure around the forehead, nose, or
    eyes
   Discolored nasal discharge or discolored mucus
    in the throat
   Reduced sense of smell
   Symptoms for > 12 weeks by definition

                    Tomassen P, et al. Allergy 2011; 66:556
       Allergy and Chronic Sinusitis
   Conflicting data regarding increased prevalence
    of chronic sinusitis in allergic patients
   Data suggests chronic sinusitis may be more
    severe in allergic patients
   Appropriate to aggressively treat allergic rhinitis
    in patients with coexistent chronic sinusitis
   Immunotherapy not convincingly shown to
    improve sinusitis in allergic patients
       Medical Approach to Chronic
                Sinusitis
   Saline lavage
   Intranasal corticosteroids
   Treat acute infections
   Treat coexistent allergic rhinitis
   Rule out hypogammaglobulinemia
   Medical treatment of hyperplastic eosinophilic
    sinusitis
   Post operative treatment of Allergic Fungal
    Sinusitis
    Chronic Hyperplastic Eosinophilic
               Sinusitis
   Eosinophilia does not indicate allergy
   Associated with nasal polyps, asthma, aspirin
    sensitivity
   Poorer prognosis after surgery
   Consider montelukast
   Aspirin desensitization for patients with aspirin
    sensitivity
Allergic Fungal Sinusitis: Diagnostic
              Criteria
   Radiologic evidence of sinusitis
   Allergic mucin in the sinus
   Fungal hyphae in the mucin or positive sinus
    fungal culture
   Absence of diabetes, immunodeficiency, or
    immunosuppressive therapy
   Absence of fungal invasion
          Allergic Fungal Sinusitis:
           Immunologic Findings
   Elevated total IgE level (67-74 %)
     May correlate with course of disease
     Increases ≥ 10 % provides high sensitivity for
      disease progression but lower specificity
   Atopy (76-100 %)
   Specific IgE against fungus (58-100 % positive
    skin tests)
   Precipitating antibody against fungus (8-89 %)
          Allergic Fungal Sinusitis:
                Management
   Surgery
   Post-operative prednisone
     0.5 mg/kg daily for 14 days
     0.5 mg/kg every other day, tapered over 3 months to
      5 mg every other day
     Continue 5 mg every other day for at least 12
      months
   Intranasal steroids
   ? Antifungal agents
                   Conclusions
   Rhinitis is NOT a trivial illness
   All rhinitis is NOT allergic
   All non-allergic rhinitis is NOT homogeneous
   Appropriate diagnosis and management (medical
    and surgical) can substantially improve the
    quality of life of patients with chronic rhinitis or
    sinusitis and improve asthma control as well

								
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