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Allergic Rhinitis by Mind Map: Allergic Rhinitis

1. Managment

1.1. Avoidance

1.1.1. Fungal Remove of moistures surfaces Replacement of contaminated material diluted bleach on non-porus surface e.g. glasses With fungocide Keep humudity <50% HEPPA filter

1.1.2. Dust mites Control humidity to <50% Dust mite cover for beddings Use HEPA High efficiency Particulate Air Vaccum Carpenting Use of acaricides Wash bedding in hot water

1.1.3. Animal May take >6months of allergen to go away HEPPA filter Ask someone to wash to the animal with warm water once a week Keep them out side of the bedroom

1.2. Pharmacological

1.2.1. Nasal Saline effective

1.2.2. Automnomic Drugs Oral and topical alpha agonist S.E for temporary use only not daily Caution in Used in Examples Intranasal anti-cholenergic good for rhinorrhea especially if combined with IN CS Used in

1.2.3. Inflammatory Steroid Intranasal steroid Systemic steroid Anti-histamine oral anti-histamine Intranasal anti-histamine Intrasal cromyln Mast Cell stabilizer Less effective than Intrasal CS minimum SE Oral anti-LT can be used alone or in combination w/ anti-histamine Particularly effective The only approved is Montelukast Omalizumab effective but not approved yet

1.3. Immunotherapy

1.3.1. Indications Evidence of sensitization to clinically relavent aeroallergen Failed, intolerance or not preferred pharmacological Rx.

1.3.2. Advantages can prevent the sensitization of other allergen Prevent the development of asthma

1.4. Surgery

1.4.1. for comorbidities Septal deviation Inferior turbinate hyper trophy sinusitis complication adenoid hypertrophy

1.5. Special Consideration

1.5.1. Pregnancy Check safety of meds Avoid oral decongestant in the 1st trimester Anti-histamines,IN CS, cromyln, montelukast are safe No initiation or escalation of IT

2. Diagnosis

2.1. SPT and sIgE

2.1.1. 70-75%sensitivity for which 1/4 pt will have -ve testing yet have true allergic disease despite it is the best test. For which you may one offer Rx. despite negative allergy testing

2.2. Elevated IgE and Eo

2.2.1. Have limited utility Typically IgE>140IU/ml Eo > 80cells/ml Very variable Not used in Dx

2.3. Nasal Nitric Oxide

2.3.1. Increase in Allergic Rhinitis

2.3.2. Decrease in sinus infection

2.4. Medication to avoid prior to SPT because they suppress

2.4.1. all anti-histamine Including Azelastine Intra-nasal anti-histamine

2.4.2. Steroid >20mg

2.4.3. Tacrolimus interfer It is OK to use Pimecrolimus CSA

2.4.4. Omalizumab after 6 months

2.4.5. Psychiatric medications TCA Benzodiazepine Quitiapine Anti-psychotic

3. DDx

3.1. Pre-school age

3.1.1. Foreign body

3.1.2. CSF leak Hx of trauma Colorless

3.1.3. CF/PCD/Immunodeficiency

3.1.4. Coanal atresia

3.1.5. Deviated Septum

3.1.6. Adenoidal Hypertrophy

3.1.7. Coaguloapthy

4. Introduction

4.1. Allergen

4.1.1. Airborn Protein or glycprotein activity Some have protease activity Activate epithelial cells

4.1.2. Hapten Drugs Occupational agent

4.2. Inflammatory mediattors

4.2.1. Immediate Preformed mediators Histamines Heparin Proteases Kinins Another way to remember it 2H 2C 2T Newly formed Prostaglandins Leukotriens Thromboxoane

4.2.2. Late phase Congestion! Begin 4-8hrs and last >24hrs cells Basophills Eosinophils Th2

5. Types

5.1. Allergic

5.1.1. Types Seasonal vs. Perinnial Perennial with seasonal exacerbation Seasonal 20% Perennial 40% Episodic Severity and duration ARIA Classification

5.1.2. Epidemiology Prevalence 20% 80% onset <age 20 yo

5.2. Non-allergic

5.2.1. Vasomotor (idiopathic) 3 criteria Not infectious Not allergic No eosinophillia Heterogenous group autonomic dysfunction Triggers Cold air Dry air Barometric pressure Strong scent IF trigger by food-->vagal Gustatory Rhinitis (specific food: capsaicin) Athlete rhinitis Rhinorrhea prominent symptoms Rx intranasal anti-histamine

5.2.2. Atrophic rhinitis Progressive non-inflammatory loss humidifying function of the nose Primary Secondary Symptoms Foul smelling Crusting Pain on inspiration (from dry nasal passage) Congestion Purulant dischage Hyposomnia/anosmia CT: Absent of identifiable turbinate Resorption of underlying bone Biopsy Squamous metaplasia Atrophy of glandular cells Rx Nasal saline irrigation Topical Abx Need surgery for crusting depridment

5.2.3. NARES Non-allergic Rhinitis w/ eosinophillia Syndrome Perennial Clinical features Investigations Epidemiology Sleep apnea At risk of Nasal polyps Predrome for AERD 50% hyper responsive airway Respond well to intranasal steroid

5.2.4. Infectious Rhinitis

5.2.5. Medication induce rhintiis ASA/NSAID Sildenafil Phosphpodiestrase inhbitor Anti-HTN ACEI BB Rhinitis medicametnosa To treat it, use OCP Illicit drugs coccaine Metamphetamine

5.2.6. Hormon-induce rhinitis OCP Puberty Pregnancy The most common is AR that gets worse in 1/3 of pregnant women Pregnancy assosciated Hypotherodism

6. Preventable factror

6.1. Multiple siblings