heent 06

Question 1

phases of allergic rhinitis

Answer 1

phase 1: sensitization (creates allergen-specific IgE)
phase 2: immediate/ early reaction ( mast cell degranulation, rapid onset of acute nasal or ocular sym due to histamine release)
phase 3: late rxn (cellular recruit of basophils, neutruphils t-lymphocytes, monocytes and eosinophils and release of multiple mediators which perpetuate inflammatory respone hours)

Question 2

risk factors

Answer 2

concomitant asthma
genes
maternal smoking
no siblings or pets in early childhood
exposure to allergens// pollution

Question 3

diagnosis

Answer 3

sx: sneezing, nasal congestion, nasal itching and rhinorrhea
- conjunctivitis
clinical history: age of onset, duration, frequency, severity, timing, suspected triggersm patterns, progression
- fam and personal history of comorbidity resp conditions
visble signs

Question 4

diagnosis testing

Answer 4

gold: skin or blood testing
- allergen-specific IgE

physical cannot distinguish

Question 5

sym of allerguc rhinitis

Answer 5

rhinorrhea, sneezing, congestion, ocular pruritis, anosmia (sometimes), chronic cough

sometimes: nunny nose, headache

Question 6

referral

Answer 6

unilateral sym
nasal obstruction w/o syms
mucopurulent rhinorrhea
posterior rhinorrhea (post nasa-drip)
pain
recurrent epistaxis
anosmia

Question 7

goals of therapy

Answer 7

relieve sym
prevent complications
improve quality of life
avoid or minimize medication side effects

Question 8

therapeutic options

Answer 8

education
avoidance
nasal saline irrigation
pharmacotherapy

Question 9

pharmacotherapy

Answer 9

oral and intranasal antihistamine
intranasal corticosterois
leukotriene receptor antagonist and allergen immunotherapy

oral corticosteroids, decongestants, other symptomatic treatment

Question 10

nasal saline irrigaton

Answer 10

may be beneficial and unlikely to have adrs
low quality evidence

Question 11

treatment principles

Answer 11

10 point visual analouge scale (VAS) to determine severity
mild: <5
moderate/severe: VAS 5 or up

assess therpay in 3-7 days:
- symptoms controlled: continue or step down or decrease to as needed or stop if not trigger present
symptoms not controlled: use alt monotherapy or step up to combo or add sym specific agent

Question 12

mild symptoms persistent or intermittent

Answer 12

one of:
oral antihistamine (2nd)
intranasal cc
intranasal cc + intranasal antihistamine (best option)

Question 13

moderate-severe intermittent

Answer 13

one of:
oral antihistamine (2nd)
intranasal cc
intranasal cc + intranasal antihistamine (best option)

Question 14

moderate-severe persistent

Answer 14

one of:
intranasal cc
internasal cc + intranasal antihistamine

step up if VAS 5 or up or if moderate-severe syms persist

Question 15

VAS 5 or up

Answer 15

step up if VAS 5 or up or if moderate-severe syms persist
- intranasal cc +/- intranasal antihistamine

Question 16

LTRA

Answer 16

only if inital therapies are ineffective or not tolerated due to limited effectiveness and risk of adrs
if they have asthma

Question 17

allergen immunotherapy

Answer 17

1st line aren’t working or preference for monotherapy or dont want nasal product
reduce severity of comorbid

indicated for positive skin test to clinically relevant allergens and poorly controlled sympotoms using maximal pharmacotherapy

MOA: changes in serum Ab levels as well as cellular changes (alt of t cell response from th2 to th1)

effective in imporving sympotoms and qol

dosing: initial dose -> escalation phase -> maintenance dose (3-5yr)
dust mite, cat, dog, grass, and ragweed

Question 18

oral cc

Answer 18

short course (5-7) for very severe

Question 19

symptomatic treatment

Answer 19

rhinorrhea, congestion, ocular

Question 20

oral antihistamines

Answer 20

moa: comp inhibit interaction of histamine with h1 receptos
1st gen avoided
2nd gen more specific for peropheral h1-receptors and limited pen to BBB
once daily
less effective than intranasal cc

Question 21

types of oral histamines

Answer 21

bilastine
cetrizine
desloratadine
fexofenadine
loratadine
rupatadine

Question 22

intranasal antihistamine

Answer 22

moa: same but also mast cell stabilizing, anti-leukotriene and anti-inflammatory
no single entitiy in canada
adr: bitter, epistaxis, headace, somnolence, nasal burning
this over oral for congestion
less effective than intranasal cc

Question 23

intranasal cc

Answer 23

moa: inhibit phase 3, inhbit inflammatory mmediator release from many cell types
imporves sneezing, itching, rhinorrhea, congestion also eye
continous use> intermittent> placebo
onset of hours/ days
adrs: dryness, burning, stinging, blood-tinged secretions, spistaxis
monitor: intraocular pressure, glaucoma nad cataracts

Question 24

types of intranasal cc

Answer 24

beclomethasone
budesonide
ciclesonide
fluticasone furoate
fluticasone propionate
mometasone furoate
triamcinolone acetonide

Question 25

LTRA

Answer 25

moa: block activity or secretion of cysteinyl leukotrienes montelukast only in canada: 15 and up for allergic 10mg po once daily adrsL depression, suicidal thinking and behavioiur, agression similar or less effective than oral antihistamines; less effective than INCS (intranasal cc= fluticasone propionate)