Chapt. 8: Allergic Rhinitis and Conjunctivitis Flashcards
1
Q
What percentage of patients with allergic rhinitis have associated symptoms of allergic conjunctivitis?
A
50-60%
2
Q
The presence of rhinitis has significant effects on the development and severity of what other disorders?
A
Bronchial asthma
Sinusitis
Middle ear disease
Dental malocclusion
3
Q
What are the 2 most common rhinitis syndromes?
A
Allergic rhinitis
Idiopathic rhinitis
4
Q
How to differentiate between the 2 rhinitis syndromes?
A
Assessment of specific IgE
5
Q
What remains the only disease-modifying treatment capable of causing long-term improvement with respect to nasal symptoms and reduction in incident cases of asthma?
A
Allergen immunotherapy
6
Q
Where has the incidence of allergic rhinitis increased?
A
Mostly in Westernized countries with a higher standard of living
7
Q
What are the risk factors for the development of allergic rhinitis?
A
Increased Risk
- female gender
- particulate air pollution
- maternal smoking
Decreased Risk
- Increased number of siblings
- grass pollen exposure
- farm environment
- mediterranean diet
8
Q
May play a key role in determining QOL, in that it may lead to daytime fatigue and poor concentration in school, resulting in learning impairment.
A
Sleep loss
9
Q
What percentage of patients with chronic rhinitis have asthma? What percentage of patients with asthma suffer with persistent nasal symptoms?
A
40%, 80%
10
Q
What is an important risk factor for worsening asthma in patients who have both rhinitis and asthma?
A
Nasal disease
11
Q
What is the percentage of patients who suffer from rhinosinusitis have allergic rhinitis?
A
30% of patients with acute sinusitis
67% with unilateral chronic sinusitis
80% with bilateral chronic sinusitis
12
Q
How does nasal allergy precipitate acute sinusitis?
A
Inducing sinus ostial edema, resulting in an impairment of sinus drainage, a shift to anaerobic conditions inside of the sinus cavity, and of bacterial proliferation
13
Q
Why does a considerable proportion of patients with allergic rhinitis have concomitant OME?
A
Pollen exposure causes ETD, which induces negative pressure in the middle ear space, followed by transudation of fluid
14
Q
Why do some children with allergic rhinitis have dental malocclusion?
A
Persistent, severe rhinitis in children may also cause chronic mouth breathing, particularly at night, which has been linked to alterations in the palatal anatomy and dental malocclusion
15
Q
This upregulates adhesion molecules on the vascular endothelium, and possible on marginating leukocytes, and lead to the migration of these inflammatory cells, including lymphocytes, eosinophils, and basophils, into the site of tissue inflammation.
A
Cytokines
16
Q
Role of the nervous system in allergic reactions?
A
Amplifying and perpetuating allergic reactions
17
Q
Why are allergic patients more responsive to stimuli to which they are exposed every day?
A
Inflammatory changes by cytokines lower the threshold of mucosal responsiveness to various specific and non-specific stimuli
18
Q
What is the pattern of congestion in allergic rhinitis?
A
Frequently alternates between both sides of the nose as a function of the physiologic nasal cycle.
19
Q
What is the pattern of sneezing in allergic disease?
A
Explosive paroxysms of 5 to 10 sneezes or more.
20
Q
Characteristic of secretions in allergic rhinitis?
A
Clear to white in color, and the presence of purulent secretions strongly indicates the possibility of chronic sinusitis or atrophic rhinitis.
21
Q
What is the percentage of patients with allergic rhinitis who have ocular s/s such as redness, itching, and watering?
A
Half
22
Q
When should a primary central nervous system lesion be considered?
A
When anosmia is the most prominent symptom and nasal or ocular symptoms are minimal or absent
23
Q
When are symptoms of allergic rhinitis the most intense?
A
During early morning hours as a consequence of circadian variations in inflammation
24
Q
What are some causes of non-allergic rhinitis?
A
Changes in climatic factors, such as temperature, humidity, and barometric pressure
25
What are some facial abnormalities noted in children with allergic rhinitis?
Retracted mandible, high-arched palate
26
What is the appearance of the nasal mucosa in patients with symptomatic allergic rhinitis?
Swollen and pale in color
27
What is the appearance of the nasal mucosa in patients with symptomatic idiopathic rhinitis?
Pink or erythematous mucous membranes
28
When should the physician consider the possibility of atrophic rhinitis?
Crusting, particularly with dried blood
29
What is "allergic shiners" an what is the pathophysiology?
Cyanosis of the infraorbital tissues, thought to be caused by venous stasis and may be seen with any chronic nasal or sinus disorder and is not pathognomonic for allergy.
30
What are the normally unseen regions during fiberoptic rhinoscopy?
Posterior nasal septum, superior nasal turbinates, middle meatus, adenoid gland, eustachian tube orifice
31
What is considered to provide the best combination of sensitivity and specificity in allergy skin testing?
Skin prick method
32
What is local allergic rhinitis (or entopy)?
Specific IgE can only be identified in the nose.
33
How to clinically confirm the diagnosis of LAR?
Nasal allergen challenge
34
What is the most accurate test for evaluating possible inflammation of the paranasal sinuses?
CT
35
What can be seen on CT scan?
Mild mucoperiosteal thickening can be seen in patients with uncomplicated allergic rhinitis and non-allergic rhinitis
36
When should radiographic studies be considered in patients with rhinitis?
Considered in patients with symptoms that are not typical of rhinitis and are unresponsive to medical therapy, such as chronic purulent rhinorrhea, alterations in sense of smell, or headaches
37
What are the differential diagnosis of chronic rhinitis? (Allergic)
Systemic
| Local (entopy)
38
What are the differential diagnosis of chronic rhinitis? (Work-related)
Irritant
Corrosive
Immunologic
39
What are the differential diagnosis of chronic rhinitis? (Rhinosinusitis)
Allergic
| Non-allergic
40
What are the differential diagnosis of chronic rhinitis? (Non-allergic)
```
Idiopathic (vasomotor)
Non-allergic with eosinophilia
Atrophic - primary/secondary
Medication related
Topical vasoconstrictors (rhinitis medicantosa) - oral medications
Excercise-induced
Cold air-induced
Gustatory
Hormonal
Aging
Systemic disease
```
41
What characterizes work-related rhinitis?
Intermittent or persistent nasal symptoms attributable to exposures incurred in a particular work environment`
42
What is the etiology of work-related rhinitis?
1. Immunologic hypersensitivity, including the presence of IgE
2. Non-allergic
43
What are the occupations that carry a high risk for development of work-related rhinitis?
Laboratory workers
Furriers
Bakers
44
What is the typical history of work-related rhinitis?
Symptomatic worsening during the work week, with improvement over he weekend and during vacations, when the putative trigger is absent
45
What occupations have irritant-exposure rhinitis?
Drywall installer - Gypsum powder
| Makeup artist - Cosmetic powder, perfume
46
What occupations have corrosive-exposure rhinitis?
Janitor - Ammonia
| Chemistry technician - Hydrochloric acid
47
What occupations have immunologic-exposure rhinitis?
```
IgE:
Baker - grain flour
Furrier, livestock breeder, veterinarian - animal dander
Food processing worker - Foodstuffs
Pharmacist - Medication powders
```
LMW substances:
Boat builder - anhydrides
48
What is CRS?
Inflammatory disease of the PNS that has been present for 12 weeks or longer
49
What are the four cardinal symptoms of CRS?
Mucopurulent drainage
Nasal obstruction
Facial discomfort
Decreased sense of smell
(2 of these must be present, along with CT or endoscopic evidence of sinus mucosal inflammation in order to establish this diagnosis)
50
What percentage of patients with CRS present with nasal polyps, which are likely to cause anosmia?
Up to 1/3
51
Another name for idiopathic non-allergic rhinitis?
Vasomotor rhinitis
52
What is the manifestation of vasomotor rhinitis?
Chronic or intermittent symptoms of nasal congestion and/or water rhinorrhea that worsen acutely in response to non-specific provocateurs, including cold air, exercise, pungent odors, smoke, alcohol, and specific physiologic states, such as sexual arousal and emotional upset.
53
What is gustatory rhinitis?
Eating causes isolated watery discharge
54
What are the laboratory tests for patients with idiopathic rhinitis?
Patients have negative responses on skin or blood tests for specific IgE, including to potential food allergens, although occasionally patients may exhibit a small number of positive reactions that are considered clinically irrelevant.
55
What proportion of patients with non-allergic rhinitis have an increased percentage of eosinophils in nasal mucosa?
Non-allergic rhinitis with eosinophilia or eosinophilic non-allergic rhinitis
56
What is atrophic Rhinitis?
Chronic condition characterized by symptoms of nasal crusting, purulent discharge, nasal obstruction, and halitosis.
57
Where is primary atrophic rhinitis most prevalent?
In areas with prolonged warm seasons, including South Asia and the middle East and is more common in women
58
What is the cause of primary atrophic rhinitis?
No known specific cause, many patients are found to have chronic bacterial infection of the nose and sinuses, due to any number of organisms, the most common of which is Klebsiella ozaenae.
59
What are some causes of secondary atrophic rhinitis?
Patients who have undergone multiple or aggressive nasal surgeries, nasal trauma, or nasal irradiation; in the case of nasal surgery, it has been referred to "empty nose sydrome". This is the more common form of the disease in the developed world
60
What is the cause of rebound congestion with repetitive use of alpha-adrenergic decongestant nasal sprays (e.g. oxymetazoline, phenylephrine) for more than a few days?
Secondary to a downregulation of the alpha-agonist receptor
61
What is the manifestation of rhinitis medicantosa?
Severe nasal congestion without other significant symptoms
62
What has also been implicated in causing rhinitis medicantosa but usually results in significantly more crusting, bleeding, and ultimately septal perforation than topical decongestant drugs?
Cocaine
63
What are the PE findings in patients with rhinitis medicantosa?
Swollen, red nasal mucous membranes with minimal discharge
64
What are the general classes of medications that have been implicated in causing rhinitis symptoms?
Antihypertensives
Drugs for erectile dysfunction
Psychiatric drugs
NSAIDs
65
What are examples of Antihypertensives that can cause rhinitis? (6)
```
ACEI
B-adrenergic blockers
Amiloride
Prazosin
Hydralazine
```
66
What are examples of Psychotropics that can cause rhinitis? (3)
Risperidone
Chlorpromazine
Amitriptyline
67
What are examples of Phosphodiesterase-5 inhibitors that can cause rhinitis? (3)
Sildenafil
Tadalafil
Vardenafil
68
What is an example of an NSAIDs that can cause rhinitis? (1)
Ibuprofen
69
What other drug can cause rhinitis?
Gabapentin
70
What percentage of women will develop rhinitis of pregnancy?
20-30% of pregnant women
71
What is the definition of rhinitis of pregnancy?
new-onset nasal symptoms (usually congestion ang/or rhinorrhea) in the absence of another known cause that lasts >=6 weeks and resolves within 2 weeks after delivery
72
What is a potential complication of uncontrolled rhinitis during pregnancy?
May cause snoring, which has been associated with increased risk of gestational hypertension, preeclampsia, and IUGR
73
What systemic diseases can be occasionally associated with symptoms of rhinitis?
Granulomatous diseases (e.g. granulomatosis with polyangiitis, sarcoidosis, midline granuloma), cystic fibrosis, ciliary dyskinesia syndromes, and immunodeficiencies.
74
In systemic disorders with rhinitis complaints, usually what other organ system is affected?
Lungs
75
Aeration of the middle turbinate bones with expansion of the turbinates
Concha bullosa
76
In what proportion of the population is concha bullosa present?
2/3
77
What is the percentage of the population with nasal septal deviation?
20%
78
Adenoidal enlargement may cause some decree of nasal obstruction in what percentage of children?
50%. The majority of these will resolve spontaneously without the need for surgical intervention.
79
What are the most common foreign bodies in the nose?
Peanuts, beads, buttons
80
Prevalence of nasal cancers?
0.001%
81
When should nasal cancer be suspected?
Older persons with unilateral nasal obstruction and bleeding of gradual onset.
82
What are anatomic abnormalities causing nasal obstruction?
```
Concha bullosa
Nasal septal deviation
Adenoidal enlargement
Nasal polyps
Nasal cancer
Nasal foreign body
```
83
Usually a more severe conjunctival disorder that most affects young males living in warm climates.
Vernal keratoconjunctivitis
84
Symptoms of vernal keratoconjunctivitis?
Ocular itching, mucus discharge, cobblestoning of the eye which may vary in severity according to the seasons
85
Represents a hypersensitivity reaction to medical appliances placed on or into the eye, including contact lens and ocular implants
Giant papillary conjunctivitis
86
Symptoms of giant papillary conjunctivitis?
Itching and a gritty sensation
87
Can affect the conjunctiva, cornea and eyelid, and is most commonly diagnosed in middle-aged adults (30-50 years of age) with atopic dermatitis.
Atopic keratoconjunctivitis
88
Symptoms of atopic keratoconjunctivitis?
Severe itching of the eyes with associated thickening and lichenification of the eyelids.
89
Characterizes viral conjunctivitis?
Can be either unilateral or bilateral, characterized by clear, watery discharge.
90
Characterizes bacterial conjunctivitis?
Usually affects one eye, associated with purulent discharge
91
Syndrome where eyes are capable of minimal tear production, creating a sensation of grittiness and discomfort?
Dry eye syndrome or xerophthalmia
92
Frequent cause of dry eye syndrome?
Medications with anticholinergic s/e... thus patients should undergo a trial of discontinuation before embarking on an in-depth evaluation.
93
Convenient and inexpensive method for documenting dry eyes?
Schirmer test
94
Occurs at the front edge of the eyelid where the eyelashes are attached
Anterior blepharitis
95
Affects the inner edge of the eyelid that comes in contact with the eyeball
Posterior blepharitis
96
Irritant reaction to ocular medications which usually occurs after long periods to use
Toxic conjunctivitis
97
Most commonly implicated in toxic conjunctivitis?
Preservatives in eye medications, contact lens solutions, and artificial tears
98
Findings in toxic conjunctivitis?
Non-specific and consist of conjunctival erythema, mucus discharge, and itching
99
Conjunctival erythema, blepharitis, and lid margin telangiectasia?
Ocular rosacea
100
Inflammation of the cornea, most often occurs in response to contact lens but may also be associated with Herpes simplex infections.
Keratitis
101
Physical findings of keratitis?
Typically presents with unilateral findings, often consisting of intense erythema and pain, and may be associated with vision loss.
102
How to distinguish keratitis from allergic conjunctivitis?
Presence of corneal infiltrates
103
May present with injection of the affected eye, but is most always associated with severe unilateral eye pain and vision loss due to corneal edema?
Angle closure glaucoma
104
HDMs are found in most places with relative indoor humidity levels higher than ______.
45%
105
What percentage of allergic rhinitis sufferers are allergic to cats?
25%
106
Most practical and effective approach to reduction of indoor cat allergen?
Removal of the cat from the indoor environment
107
What are the peak pollen hours?
Between 11:00 hours and 15:00 hours
108
When do oral antihistamines begin to provide relief of histamine-mediated s/s such as sneezing, itching, rhinorrhea and eye symptoms (not as effective in alleviating nasal congestion)?
Within 1 to 2 hours
109
What are available intranasal antihistamines?
Azelastine HCl and Olopatadine HCl. Have a more rapid onset of action than oral antihistamines, usually within 15-30minutes, and result in significant reduction of nasal congestion as well as itching, sneezing, and runny nose. These medications may cause taste alteration and occasionally somnolence.
110
MOA of both topical and systemic decongestants?
Alpha-adrenergic stimulation, which results in vascular constriction and a reduction of nasal blood supply to the sinusoids.
111
Name an example of a catecholamine topical decongestant.
Phenylephrine
112
Name 2 examples of an imidazole derivative topical decongestant.
Xylometazoline
| Oxymetazoline
113
Do topical decongestants have systemic side effects?
No. However, in children there have been rare case reports of seizures
114
When these topic decongestants are used for more than ____ days, rebound nasal congestion may develop in some patients.
5 days
115
What should be the primary use of topical decongestants?
To reduce nasal congestion in patients with acutely severe rhinitis in order to facilitate the penetration of intranasal corticosteroids.
116
Do oral decongestants cause rebound congestion same as topical formulations?
No
117
What are the most common side effects of oral decongestants?
Insomnia and irritability, which can occur in as many as 25% of patients taking these medications.
118
What is a serious side effect of decongestants?
At normal doses, aggravation of hypertension and cardiac arrhythmias.
119
Taken in overdose, what are the side effects of oral decongestants?
Renal failure
Psychosis
Strokes
Seizures
120
What are the most potent drugs available for the management of allergic rhinitis?
INCS
121
When do INCS begin to have effects?
Within 7 to 8 hours of dosing, although some reports demonstrate an effect within 2 hours.
122
What is the main side effect of INCS?
Local nasal irritation (5-10% of patients) and epistaxis (4-8%)
123
What is the recommendation for pediatric patient monitoring for those using INCS?
Evaluated every 6 months using a stadiometer to monitor growth
124
Are INCS shown to be effective in the treatment of non-allergic rhinitis?
Yes.
125
Among the available preparations, what are approved by the FDA for the treatment of non-allergic rhinitis in addition to allergic rhinitis?
Fluticasone propionate
| Fluticasone furoate
126
Why is the role of systemic steroids in the treatment of rhinitis limited?
Because of their adverse effects and the limited morbidity of the disease
127
In what group of patients is systemic corticosteroids best reserved for?
Patients with any type of rhinitis who present initially with severe nasal obstruction
128
What is the prescribed course for rhinitis presenting with severe nasal obstruction?
Oral prednisone, 30 mg daily for 3 to 5 days. This will usually significantly decrease nasal edema and allow for enhanced penetration of ICNS
129
What is a catastrophic risk of intramuscular injections of corticosteroids for seasonal allergic rhinitis?
Aseptic necrosis of the femoral head
130
What are other long-term effects of systemic corticosteroids?
Cataracts
| Osteoporosis
131
Has comparable efficacy with oral antihistamines for the relief of all ocular and nasal symptoms of allergic rhinitis, including congestion, rhinorrhea, and sneezing?
Monteleukast
132
Available preparation for cromolyn sodium?
Intranasal cromolyn sodium 4%. Is available OTC and has been shown to be clinically effective in the treatment of allergic rhinitis.
133
When is the treatment timing for cromolyn sodium most effective?
When dosing is staged before the onset of symptoms
134
What is the recommended dosage frequency of cromolyn sodium?
Four times daily. But the drug is very safe, especially in children and pregnant women.
135
What are useful in the treatment of those patients in whom rhinorrhea is the predominant complaint?
Anticholinergic drugs
136
What drug has little or no systemic effect when admininstered intranasally and has been shown to be effective in controlling watery nasal discharge in perennial allergic rhinitis? (Can also be used for rhinitis associated with gustatory rhinitis and rhinorrhea induced by exposure to cold, dry air)
Ipratropium bromide
137
These medications are prescribed as adjunctive agents for patients with rhinoconjunctivitis and as a primary medication for patients with isolated allergic conjunctivitis.
Topical ocular antihistamines
138
When do topical ocular antihistamines begin to work?
Within a few minutes and have a 12 to 24 hour duration of action.
139
Why do INCS reduce allergic eye symptoms?
Reduced intranasal inflammation, which in turn inhibitis the nasal ocular reflex initiated by allergen contact to the nasal mucosa
140
With respect to combination treatment of eye symptoms, which was more effective in treating?
Intranasal fluticasone propionate plus intraocular olopatadine.
141
What is the principal advantage of immunotherapy over pharmacotherapy?
It is generally more efficacious and that two consecutive years of treatment results in persistent tolerance.
142
When should immunotherapy be considered?
Severe allergic rhinitis unresponsive to usual pharmacotherapy and allergen avoidance measures
Allergic rhinitis complicated by other disorders, particularly new-onset or worsening asthma
Occurence of significant adverse effects from medications for rhinitis
143
What is the predominant route of administration for immunotherapy?
SQ
144
Patients with moderate to severe symptoms of allergic rhinitis should be evaluated after how many weeks?
After 2 to 4 weeks to assess their response to therapy
145
For residual nasal congestion, what may be the most useful of all options?
Addition of an intranasal antihistamine
146
If rhinorrhea persists as a primary problem, what may be the most useful of all options?
Ipratropium bromide
147
In what condition is nasal saline wash extremely important?
In the management of nasal crusting, as seen in atrophic rhinitis
148
Does nasal saline wash have an effect on nasal congestion?
No. Other medications will be important in alleviating this symptom
149
In patients with chronic congestion, what should be administered as a first-line pharmacologic agent?
ICNS or intranasal azelastine, used on an intermittent basis
150
What can be prescribed in patients with intermittent acute, watery rhinorrhea caused by irritant or cold air exposure, exercise, or food?
Ipratropium bromide before symptoms occur
151
For patients using medications for systemic diseases such as antihypertensives, how should their medications be considered?
Best accomplished with topical therapy in order to avoid drug interactions and/or additional systemic adverse effects
152
How to manage pregnant women with rhinitis?
Non-drug therapies should be tried first. Nasal rinsing with normal saline helps to remove thick nasal secretions and OTC mechanical nasal dilators may improve nasal congestion and snoring at night in some women.
153
If non-drug therapies does not work in pregnant women, what is the next step?
Nasal cromolyn, one spray 4x daily. It has excellent safety profile and an FDA pregnancy category B.
154
If 2 week course of cromolyn is not helpful for pregnant women, what is the next course of action, particularly if nasal congestion is still present?
A trial of INS. Use Budesonide because of pregnancy category B
155
How to give budesonide nasal spray in pregnant women?
64 mcg/actuation 1 puff per nostril 2x a day or 2 puffs once a day in the morning.
156
When should oral antihistamines in pregnant women be considered?
When the primary complaint is rhinorrhea, sneezing, and pruritus and the patient prefers oral therapy.
157
What are appropriate drugs to give to pregnant women?
Diphenhydramine
| Chlorpheniramine. These are frequently the DOC in pregnant women.
158
What other antihistamines have been extensively studied during pregnancy?
Loratadine and Cetirizine both belong to pregnancy category B
159
What medications should be avoided, if possible, during the first trimester because of congenital malformations such as gastroschisis and small intestinal atresia?
Phenylephrine
| Pseudoephedrine
160
How should ongoing allergen therapy be continued during pregnancy?
Allergen extract doses should be maintained and not increased until the completion of the pregnancy. For these same reasons, immunotherapy should not be started during pregnancy.
161
What are the two most important aspects of treating rhinitis in older patients?
Improving intranasal moisture content
| Removing dried secretions
162
Why do INS may cause more bleeding in elderly people than is usually seen in younger people
Owing to the increased fragility of the nasal mucous membranes in this population.
163
In elderly patients what is the role of older-generation oral antihistamines?
Should generally be avoided because of their potential to sedate or cause anticholinergic effects
164
In elderly patients what is the role of older-generation oral decongestants?
Should be avoided owing to possible adverse effects on blood pressure (hypertension), cardiac rythm, CNS, and urinary tract
165
When should a patient be referred to an allergist?
1. Patients whose rhinitis symptoms have not responded adequately to combination pharmacotherapy
2. Patients with significant adverse side effects due to pharmacotherapy
3. Patients with secondary complications from their rhinitis, including recurrent or chronic sinusitis, nasal polyposis, recurrent or persistent middle ear disease, and poorly controlled asthma
4. Patients with positive in-vitro or skin tests to a perennial allergen in order to consider and implement a program of allergen avoidance.
166
When is referral to an otolaryngologist important?
For surgical treatment for nasal polyposis, chronic sinusitis, significant adenoidal enlargement, or anatomic obstructions
