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123 Cards in this Set
- Front
- Back
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What is one of the most common diseases in the US?
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Allergies
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After the common cold, what is the most common cx of sick days?
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Allergies
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What are allergies a precursor to?
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sinusitis, otitis, asthsma
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What are 2 other names for allergic rhinitis (AR)?
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SAR seasonal allergic rhinitis
CAR chronic allergic rhinits |
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What is rhinitis?
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inflammation & edema of the nasal lining/mucous membranes of nose
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What are 3 common cx of rhinitis?
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*Allergic
* Non-allergic (bright sunlight, cold) * Infectious |
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What are some other cx of Rhinitis?
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Occupational non-allergic
NARES syndrome Perennial non-allergic rhinitis atrophic rhinitis Horomonally induced exercise induced Medication induced gustatory Anatomic/Mechanical obst. |
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What are some types of allergic rhinitis?
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Seasonal
perennial Episodic |
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What type of immune reaction is Allergic Rhinitis?
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IgE mediated hypersensitivity reaction
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What are some cx of Allergic?
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inhaled seasonal pollens such as tree grass, "hay fever"
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What are pereniall allergens?
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dust mites, pet dander, cockroaches, molds, indoor pollutants, cigarette smoke
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What is the tendancy of perennial allergens?
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to be more cyclic
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What is another name for non-allergic rhinitis?
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vasomotor rhinitis
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how does vasomotor work?
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Autonomic response -> vascular dilation of the nasal submucosal vessels
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What triggers the vasomotor rhinitis?
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Temp or humidity changes, odors, selected drugs, emotional responses, body positions (laying down)
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What type of rhinitis is atrophic rhinitis?
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perennial form of non-allergic rhinitis
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what is atrophic associated with?
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the atrophy of nasal bones and nasal lining in the geriatric population
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What are Nasal polyps?
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benign overgrowths of the nasal mucous membranes & connective tissue
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why are nasal polyps seen in pregnancy?
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Due to increase in progesterone increases polyps and mucous production
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What is rhinitis medicamentosa?
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abuse of nasal decongestants such as Afrin that lead to rebound edema of the nose with continuous use
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What is NARES syndrome?
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non-allergic rhinitis eosinophilia
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What causes NARES?
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usually from infection or medication
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What is hormonal rhinitis?
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transient rhinitis associated with pregnancy due to hormonal influences
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What is Mechanical rhinitis?
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rhinitis due to deviated septum or foreign body, usually seen in Peds
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What is drug induced rhinitis?
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rhinitis usually caused by nasal inhalants as well as illicit drugs like cocaine, methamphetamines
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What is gustatory rhinitis?
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rhinitis caused by hot, spicy foods.
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What is another name for infectious rhinitis?
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common cold
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What is the most common cause of infectious?
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Rhinovirus
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What are less common causes of infectious?
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coronavirus, influenza, parainfluenza, & adenovirus
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Can bacteria cause infectious?
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yes, but less common
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Why is infectious rhinitis concern if spread to sinus?
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because it can track to brain
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What is the prevalence of allergic rhinitis?
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Usually more common in males until age 40, especially in males under 20
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What is the #1 complaint that brings pt's in for allergic rhinitis?
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respiratory tract complaint
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How many people in the US have allergic rhinitis?
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20% or 60 million people
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Is Allergic rhinitis a persistant disease?
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Yes, complete remission is very unusual only happening to 17%
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What is the percent of office visits for allergic rhinitis?
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2.5% of all office visits
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How many lost school & work days for AR?
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2 million school, 6 million work
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How many restricted work days for AR?
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28 million
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What are the costs for AR?
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2.4 billion in rx & OTC meds,
1.1 billion in MD billing |
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What are some risk factors for AR?
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Family Hx of atopy (allergies)
Male sex Birth during pollen season Firstborn Early intro of formula & food Early use of ABX Cigarette exposure Exposure to indoor allergens Elevated or presence of IgE |
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What are some differential dx for AR?
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viral URI, Foreign body, Hormonal (OC's/preg), Sinusitis (bacterial), nasal polyps, Adenoid hypertrophy, otitis media, hypothyroidism
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Why is hypothyroidism a differential dx for AR?
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because this disease can change the amount of nasal discharge, usually increases
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What are important things to ask when taking history?
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Onset, duration, associated symptoms, treatments, relationship to triggers, hx of atopy, hx sinusitis, hx familial
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What are associated symptoms of viral or bacterial rhinitis?
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fevers, aches
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what are symptoms of AR?
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Rhinorrhea, congestion, sneezing, pruritis of nose, palate, & eyes, PND, mouth breathing, ear fullness or "crackling" , dental malocclusion
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what is the typical look of someone with AR?
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mouth open, allergic shiners, palatal click, nasal "salute"
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What 2 areas should be assessed with AR?
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HEENT, Cardio-pulmonary
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What are typical findings of the face/sinuses with AR?
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BILATERAL minimal tenderness overlying the involved sinuses
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What does it mean if sinus pain is severe and unilateral?
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Possibly Sinusitis
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What are typical Ear findings with AR?
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chronic middle ear abnormalities and eustachian tube dysfunction
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Typical nasal findings with AR:
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pale, bluish hue or pallor with boggy mucosa, turbinate edema, watery discharge
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What if the discharge from nose is purulent?
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most likely bacterial infection
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What are typical findings of the Mouth with AR?
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PND, posterior pharyngeal cobble stoning, & halitosis
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Why is Halitosis found?
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d/t mouth breathing that increases bacteria & dental caries
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Typical findings of the chest in AR?
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usually normal, may have cough d/t PND with potential for wheezing/athsma. Cardio is nml
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With polyps, what is usually seen?
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Chronic bloody nose, d/t increased vascularity of polyp
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what causes nasal septal perforations?
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piercings & drug use
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When trying to diagnose AR, what should be ruled out?
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Infection
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What are signs of infection vs. AR?
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abrupt onset vs. biphasic
unrelated to seasonal allergens Fever purulent discharge from sinus purulent mucous Unilateral findings! |
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What are typical diagnosic tests with AR?
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Nasal exam
flexible fiberoptic rhinoscopy nasal cytology skin testing RAST |
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What are you comparing in nasal cytology?
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Eosinophils & neutrophils
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What do the presence of eosinophils indicate?
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NARES or AR d/t immune response
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Why is skin testing a good diagnostic test?
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because it assesses the biologic relevent IgE and is very convenient, safe , and cheap
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When do you think AR?
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when there are reoccuring URI, sneezing, pruritis, rhinorrhea
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What is priming?
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when after exposure to an allergen, less antigen is required to elicit the allergic response
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What is needed for successful treatment of AR?
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pt education re:
environment, non Rx drug therapy, prescription drugs, & identification of allergen (referral) |
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What is the WHO symptomatic classification of allergic rhinosinusits based on?
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Frequency & Severity
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What qualifies as intermittent?
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< 4 days per week for <4 weeks
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What qualifies for Persistant?
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> 4 days per week for > 4weeks.
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What qualifies as moderate or severe allergic rhinosinusitis?
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sleep disturbance, impairment of school/work, impairment of ADL, leisure, sports
troublesome symptoms |
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How is allergic rhinosinusitis managed?
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allergy identifycation/avoidance
enviromental control pharmocological treatment allergen immunotherapy Anti IgE therapy Treat infection prn |
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What are nonpharmocologic Tx for Rhinitis?
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Hydration (keep moist & flushed)
intranasal irrigations with saline solutions avoidance of triggers |
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What are some environmental allergens that can be controlled?
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dust mites, pollens, & pets
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How are Dust mites controlled?
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Enclose mattress/box spring
Wash linens on hot (130 deg) reduce indoor humidity to <50% Consider use of benzyl benzoate or tannic acid in wash |
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How do you control pollens?
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avoid fresh cut grass, utilize AC
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How are pet allergens controlled?
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pet removed from house when possible, frequent bathing of cat (every 2 weeks), Use of HEPA filter
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What are common allergic triggers?
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Pollens
Dust mites, cockroaches, fleas Animal Dander mold Cigarette exposure |
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What are some non prescription drug therapies for allergies?
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decongestants for symptomatic benefit only, Saline nasal sprays, first generation anti-histimines, second generation anti-histimines
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What do saline nasal sprays do?
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Help with symptoms and minimize time of exposure of antigen to nasal mucosa
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What is problem with first generation antihistamines?
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effective, but SEDATE (benedryl)
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What is problem with second generation antihistamine?
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Expensive (claritin)
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What is used in pharmocologic management of AR?
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the first line treatment is intranasal steriods
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Why are intranasal steriods first line tx for AR?
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because when they are taken daily as prophylactially, they are more effective than mast cell stabilizers
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How should intranasal steriods be taken?
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uninterupted use is needed for max response, should be taken daily & continue use with cold/sinusitis
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What does intranasal steriods help with in respiratory tract?
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They improve lower respiratory symptoms (asthma) when used in upper respiratory track
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When are topical intranasal steriods effective?
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several days after initiation of therapy
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What is the trade name of beclomethasone & the dose?
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Beconase AQ, Vancenase AQ
1 spray = 42ug 1-2 spray each nostril BID to TID |
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What is the trade name of Triamcinolone & the dose?
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Nasacort AQ
1 spray = 55ug 1-2 sprays to each nostril QD to BID |
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What is the trade name of Flunisolide and the dose?
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Nasarel
1 spray = 29 ug 1-2 sprays each nostril BID |
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What is the trade name of Mometasone & the dose?
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Nasonex
1 spray = 50ug 2 spray each nostril QD |
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What is the trade name of Budesonide & the dose?
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Rhinocort Aqua
1 spray = 32 ug 4 sprays each nostril QD |
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What is the trade name of Fluticasone & the dose?
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Flonase
1 spray = 50ug 1-2 spray each nostril QD |
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What is the most important adjunct to INS?
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Antihistamines
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What do Antihistamines do?
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competatively block H1 receptor sites on mast cell and prevent it's degranulation and release of inflammatory & chemotactic mediators
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What to antihistamines relieve?
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itching, rhinorrhea, sneezing, lacrimation, periorbital edema...NOT NASAL CONGESTION
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What types of rhinitis are antihistamines useful for?
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AR, Vasomotor rhinitis, & infectious rhinitis
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What are 1st generation antihistamines?
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Brompheniramine, chlorpheniramine, diphenhydramine--the benedryls
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What are some side effects of the benedryls?
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Can cause sedation, should use with caution in school aged children
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What are the 2nd generation antihistamines?
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fexofenadine (allergra)
Loratadine (claritin-OTC) Desloratadien (clarinex-RX) Cetirizine (zyrtec) |
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What population should use 2nd gen. antihistamine?
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school children
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what do oral decongestants do?
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cause vasoconstriction, decrease blood supply to nasal mucosa, decrease mucosal edema, and can be used with antihistamines
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What are 9 adverse effects of decongestants?
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nervousness, irritability, insomnia, headache, urinary hesitancy, palpitations, Tachycardia, HTN, nausea
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What are anticholinergic adverse effects of antihistamines?
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dry mouth & eyes, impotence d/t vasoconstriction, urinary hesitancy, glaucoma
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What are some CNS adverse effects of antihistamines?
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sedation, Rarely simulation (usually in kids), confusion, cognative impairment
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What are some misc. adverse effects of antihistamines?
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Wt. Gain, hypersensitivity, pronounced QT interval, ventricular arrhythmias
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What are some topical decongestants and how long should they be used?
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Oxymetazoline (neo-synephrine)
Xylometazoline (Otrivin) Phenylephrine (Afrin) Limit to 3 days to avoid rebound congestion |
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What are 4 other types of meds for AR?
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Leukotriene inhibitors, intranasal anticholinergics, mast-cell stabilizers, mucolytics
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What is an example of leukotriene inhibitors?
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montelukast or singular
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What is an example of intranasal anticholinergics & what do they do?
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Ipatropium (Atrovent nasal spray), may help dry mucous membranes
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What is an example of mast cell stabilizers & what do they do?
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Cromolyn (nasalcrom), target specific immunologic pathways
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What is an example of a mucolytic & what other type of medication is it used with?
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guaifenesin (hytuss) or Mucinex, use with a decongestant
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When is immunotherapy used?
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when a pt hasn't responded to pharmacologic therapy
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What is immunotherapy?
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Series of injections (allergy shots) with specific allergens, 1 or 2 weekly for 6mo-24mo
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How does immunotherapy get started?
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With referral to allergist after authorization, skin testing & is only performed by a trained specialist d/t risk of anaphylaxis
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What is the effectiveness of immunotherapy?
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33/33/33
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How is vasomotor rhinitis tx?
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saline solution nasal spray, antihistamines (although controversial), intra-nasal anticholinergics (some relief)
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How is atrophic rhinitis tx?
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guaifenesin for stimulation & thinning of mucous, or intranasal saline spray
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How long is AR treated for?
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PRN for symptom relief, often there is long term tx with intranasal corticosteriods and antihistamines
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What should pt's expect with the treatment of AR, vasomotor or atrophic?
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they are ongoing probs that are managed, NOT CURED. Follow up 2-4 wks after starting tx for effectiveness
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What are special considerations for geriatrics?
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meds should be used with caution and adverse reactions often occur, interactions with other medications must be taken into consideration.
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When should OTC decongestants be used with caution?
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for pt. with diabetes, HTN, or glaucoma
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What is the relationship of AR to asthma?
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28-50% have both & 85% of asthmatics have + skin test to at least 1 allergen ass. with AR
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What skin diseases are associated with asthma & AR?
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atopic dermatitis (eczema, AD)
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