Allergic Rhinitis e-Module

Question 1

Rhinitis definition

Answer 1

inflammation of nasal mucosa

Question 2

how much of the population does rhinitis affect

Answer 2

40%

Question 3

Rhinitis is the presence of one or more of what symptoms

Answer 3

sneezing
rhinorrhea
nasal congestion
nasal itching

Question 4

what is the most common form of chronic rhinitis

Answer 4

allergic rhinitis AKA hay fever
25% of CAN pop
+prevalence is increasing

Question 5

What is AR

Answer 5

systemic
IgE antibody-mediated
inflammatory disease

Question 6

what characterizes AR

Answer 6

inflammation (swelling and or irritation of inside of nose (nasal mucosa) following allergen inhalation

Question 7

classifications of allergens

Answer 7

indoor and outdoor

Question 8

outdoor allergens

Answer 8

grass or tree pollen

mould

Question 9

indoor allergens

Answer 9

dust mites and insects

animal dander

Question 10

impacts of AR

Answer 10

negative impacts on social life, sleep, concentration ability, school performane, wrk productivity

Question 11

where is prevalence hgihest

Answer 11

school aged children

-may be more common in children with history of asthma and atopic dermatitis

Question 12

atopic triad

Answer 12

AR, asthma, atopic dermatitis

Question 13

How get AR

Answer 13

genetic predisoposition

• 1 parent affected, children 30% chance dev
• 2 parents –> 50%

Question 14

AR localization

Answer 14

historically
-nose and nasal passages

Current evidence
-component of systemic airway disease involving entire respiratory tract

Question 15

allergy/sinus relief is in top 10 OTC cat in CAN (T/F)

Answer 15

True

Question 16

How RPh optimize care for AR patients

Answer 16

need to ID patient cohorts who self-select and are at high risk of mismanagement
—> opportunity for RPh to enegage pateints and encourage discussion abt AR mngmnt

Question 17

Pathophysiology and Etiology

Answer 17

multifactorial disease induced by gene-environment interactions

characteristic symptoms are result of an antigen-antibody mediated reaction
-3 phases

Question 18

what are the 3 phases of the antigen-antibody mediated reaction

Answer 18

sensitization
immediate response
late phase reaction

Question 19

Sensitization

Answer 19

• allergen enters nose –> sensitizes mucosal mast cells
• sensitization occurs via t-cell release of cytokines
• cytokines promote allergen-specificIgE antibody production by plasma cells
• IgE binds to mast cells and basophils

THIS FIRST PHASE OCCURS ON 1ST CONTACT WITH ALLERGEN
-second and third phase are on re-exposure to allergen in sensitized individual

Question 20

Immediate response

Answer 20

early phase reaction occurs within minutes of exposure
-lasts 30-90 minutes

allergen bound to allergen specific IgE and the sensitized mast cells release preformed mediators
+histamine
+prostaglandin D2
+kinins

inflammatory mediators
-attract, recruit and activate additional inflammatory mediators into nasal mucosa —> late-phase response
+eosinophils, neutrophils and T lymphocytes

Question 21

Late reaction

Answer 21

associated with chronic inflammation charcterized by migration of inflammatory cells
+eosinophils, monocytes, macrophages, basophils

begin 4-8 hours after allergen exposure and peak 12-24 hours

release of cytokines chemokines and growth factors
-further perpetuate inflammatory response

results in recurrent symptoms that often persist
-usually nasal congestion

Question 22

Signs and symptonms

Answer 22

Nasal obsturction (congestion)
sneezing
nasal itching
rhinorrhea
Postnasal drainage (postnasal drip)
irritability
fatigue

Question 23

Common symptoms patients rarely report directly

Answer 23

subset of patients:
concomitant allergic conjunctivitis
\+bilateral ocular itching
\+redness
\+tearing
\+burning

Other symptoms

• facial P (over cheeks and forehead
• itchy throat/palate
• ear fullness and popping

Question 24

Clinical presentation of AR depending on phase of allergic reaction

Answer 24

Sensitization phase
- asymptomatic

Early response (cts to late response)

• sneezing,
• rhinorrhea,
• nasal and palatal pruritis,
• congestion

Late Response

• nasal congestion is particularly common
• fatigue
• malaise
• irritability
• neurocognitive deficits (possible)
• allergic shiners
• morgan’s lines
• transverse nasal creases

Question 25

Physical exam: Face

Answer 25

``` Allergic facies -highly arched palate -open mouth (chronic mouth breathing) -dental malocclusion TYPICALLY SEEN IN CHILDREN WITH EARLY ONSET AR ``` OTHER: - frequent gimacing - twitching face and nose (itchy mucus membs) younger children typically dont blow nose - frequently rub, snort, sniff, cough, clear throats - scratch their itchy palates with their tongues, producing a clicking sound

Question 26

Physical signs: eyes

Answer 26

Dennie-morgan lines -accentuated lines or folds below lower eyelids that may become more noticeable with age ---> suggest concomitant allergic conjunctivitis Allergic conjunctivitis -ocular itching, burning, tearing, conjunctival injection (redness faiding twd edges) Allergiv shiners - infraorbital edema and darkening due to subcutaneous venodilation - more severe disease more pronounced discoloration under eyes

Question 27

Physical exam: nose

Answer 27

``` allergic salute -transverse nasal crease casued byrepeated rubbing and pushing/wiping tip -upward motion -try and relieve itching and open airway +more common in children ``` Nasal mucosal swelling, bleeding bluish or pale, thin secretions nasal polyps or other structural abnormalities visible by internal endoscopy

Question 28

physical signs: posterior oropharynx

Answer 28

postnasal drip - nasal passages obstructed, rhinorrhea may be visible dripping down posterior pharynx - leads to cough/ frequent throat clearing - constant swallowing or halitosis lymphoid hyperplasia -hyperplastic lymphoid tissue lining posterior pharynx (resembles cobblestones) tonsillar hypertrophy -persistently enlarged tonsils

Question 29

physical exam: ears

Answer 29

-generally normal - tympanic membranes may retract - serous fluid may accumulate behind TMs of patients with seig nasal mucosal swelling - eustacian tube dysfunction pneumatic otoscopy --> asses eustachian tube dysfunction valsalva's maneuver --> asses for fluid behind ear drum

Question 30

physical exam:sinuses

Answer 30

palpitation of sinuses for sensitivity maxillary tooth sensitivity

Question 31

physical exam: chest and skin

Answer 31

Wheezing (sign of concurrent asthma atopic disease

Question 32

what is one of most important sequalae of untreated AR

Answer 32

sleep disturbed breathing

Question 33

Cognitive and psychiatric issues: children/adolescents

Answer 33

- ADHD - lower exam scores during peak pollen seasons - poor conc - impaired athletic performance - low self esteem

Question 34

Cognitive and psychiatric issues: in adults

Answer 34

- anxiety - depression - reduced academic performane - reduced work productivity (lower than that of patients with asthma) - impaired sexual performance - lower quality of life scores

Question 35

Classification: traditional

Answer 35

perennial (throughout year) seasonal (specific season) FALLEN OUT OF FACOUR -seasonal allergies may exp symptoms year-round and perennial may experioence symptoms intermittently

Question 36

modern classification of AR

Answer 36

based on symptom duration AND severity - intermittent or persistent - mild, moderate, severe

Question 37

Intermittent AR

Answer 37

<4 days/wk OR <4 consecutive weeks

Question 38

persistent AR

Answer 38

>4days/wk AND >4 consecutive weeks

Question 39

mild symptoms

Answer 39

normal sleep symptoms not bothersome no impairment of daily activities, sports, leisure normal work/school

Question 40

moderate/severe

Answer 40

abnormal sleep OR symptoms are bothersome OR impairment of daily activities, sports, leisure OR problems at work/school

Question 41

how subjectively quantify patient symp severity

Answer 41

VAS - visual analogue scale For AR, usually asked over past 24 hours how troublesome are allergy symptoms (0-10) 10cm horizontal line -not bothersome -----------------------very bothersome

Question 42

VAS score less than 2

Answer 42

well-controlled AR

Question 43

VAS score [2,5)

Answer 43

partly controlled disease

Question 44

VAS score 5 or more

Answer 44

uncontrolled AR

Question 45

MASK-air

Answer 45

reliable valid highly engaging tool treatment scroll list VAS to assess AR control and school/work productivity

Question 46

MASK-air VAS questions

Answer 46

``` VAS 1 (overall symptoms): “Overall, how much are your allergic symptoms bothering you today?” VAS 2 (Rhinitis): “How much are your nose symptoms bothering you today?” VAS 3 (Conjunctivitis): “How much are your eye symptoms bothering you today?” VAS 4 (asthma): “How much are your asthma symptoms bothering you today?” ```

Question 47

Protective and risk factors

Answer 47

falmily history = one of strongist predictors of dev of AR Others: - male gender - birth during pollen season - firstborn status - overweight - maternal exposure to indoor allergens sa dust mite allergen - serum IgE >100IU/mL before age 6 - presence of allergen-specific IgE

Question 48

SCHOLAR

Answer 48

S: main & associated symptoms: nasal pruritus, congestion, rhinorrhea, sneezing, eye involvement C: characteristics of allergic symptoms: frequency, severity: VAS score, QoL impact H: history of AR O: onset/timing/pattern/seasonality of symptoms (e.g., intermittent, persistent) Note: It’s not uncommon for patients to attribute persistent nasal symptoms to a “constant cold” and so it remains imperative to document both the duration and frequency of these “colds”.10 L: location of symptoms (e.g., nose, eyes, palate) A: aggravating factors (e.g., triggers, irritants) R: remitting factors (including therapies tried, regimens followed, and subsequent responses)