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Chronic rhinitis & sinusitis :butterfly: (Rhinosinusitis (ChronicâĶ
Chronic rhinitis & sinusitis
:butterfly:
Chronic rhinitis
:two: groups
:star::star::star:
Allergic rhinitis
Immmunologic nasal response, primary mediated by IgE
(Type 1 hypersen)
:gear: PathoPSO:
2 main mecha
Sensitization
#
Allergen comes in âĻ stimulate IgE Ab :arrow_up: âĻ these IgEAb will float in bloodstream
Reexposure
When Allergen appears again âĻ stimulate these IgE already in bloodstream âĻ Inflammatory process
:rabbit:
Classification
based on ARIA guideline
Timing
Intermittent
: <4 days/wk or <4 wk āļāļīāļāļāđāļāļāļąāļ
Persistent
: âĨ 4 days/wk
and
âĨ 4 wk āļāļīāļāļāđāļāļāļąāļ
Severity
Mild
Moderate-Severe
got 1 of these
Abnormal sleep
Impairment of daily activities, sport, leisure
Abnormal work & school
Troublesome symptoms
4 groups:
Mild, intermittent
Mild, persistent
Moderate-severe, intermittent
Moderate-severe, persistent
Dx
fr
Hx & PE
Classical symptoms (āļāļąāļ āļāļąāļ āļāļēāļĄ āļāđāļģāļĄāļđāļāđāļŦāļĨ)
+/- āļāļąāļāļāļē, āļŦāļđ, āđāļāļāļēāļāļāļēāļ, āļŦāļđāļāļ·āđāļ
Hx of childhood allergy, FxHx of allergy
Allergic salute
Allergic shiner (Fr turbinate congestion â vein congestion under eyes)
Pale & swelling nasal mucosa
Clear watery D/C
Conjunctival injection
:label:
Inx
Find
IgE
via
Skin:
Skin prick test
āļāļĩāļāļŠāļēāļĢallergen ID then observe skin reaction
Serum:
Total & Specific IgE
Shock organs
Nose:
nasal challenge test
:star:
gold standard
Conjunctiva
Bronchial
:green_apple:
Rx
Education
Allergy āđāļāđāļāđāļĢāļāļāļĩāđ
āļĢāļąāļāļĐāļēāđāļĄāđāļŦāļēāļĒ
, āļĄāļĩāđāļāđāļĢāļąāļāļĐāļēāļāļēāļāļēāļĢ
āļāļēāļāļēāļĢāđāļāļīāļāļāļēāļāļāļ°āđāļĢ?
Allergen avoidance
eg āļāļ§āļ house dust mite, cockroach
Medications
:cat:
Anti-histamine
1st gen
2nd gen
That
can give to preg woman
Diphenhydramine
CPM
Loratadine
Cetirizine
Levodetirizine
:cat:
Decongestant
Oral form :!:
Pseudoephedrine
Risk of
Gastroschisis
& Vascular disruption in
1st tri
mester
Precaution in
pregnancy
Pass via Breastfeeding
:cat:
Intranasal corticosteroids
I/C :check::
Persistent
and/or
Moderate to severe
Purpose: :arrow_down:inflam, :arrow_down:capillary permeability, :arrow_down:mucous production, Vasoconstriction
+/-
Immunotherapy
I/C
:Check:
Unavoidable allergen
Severe symptoms > 1 yr
Fail medication or Canât tolerate to SE
Working?
:check: in
Insect sting, Inhalant allergen
:green_cross: not work in Food allergy, Atopic dermatitis
Benefits
Ds modifying Rx
Prevention of allergic to new substances
Prevent asthma in AR pt
:arrow_up: long term outcome
+/- Monoclonal anti-IgE Ab
+/-
Surgery
(not rly help)
do in
Deviated nasal septum
Rhinosinusitis
Turbinate hypertrophy
Vidian nerve neurectomy
Non-allergic rhinitis
Infections
NARES (Non-AR with Eosinophil syndrome)
Vasomotor rhinitis (got irritant of vasomotor tone)
Others: Ciliary dyskinesia, Atrophic rhinitis, Hormonally-induced, Exercise, Drug-induced, Reflex-induced, Occupational rhinitis
Conditions that may
mimic symptoms of rhinits
Structural/Mechanical factors
Inflammatory/Immunologic process
CSF rhinorrhea
CSF leak outside+Hx trauma
Clinical sign :star: :
āđāļāđāļ āļŦāļĢāļ·āļ āđāļ âĻ āļāđāļģāđāļŦāļĨ
āļāđāļĄāļŦāļāđāļēāđāļĨāđāļ§āđāļŦāļĨ
Teapot sign
Inx of choice: CT
Rhinosinusitis
Adult
criteria (EPOS2012)
Symptoms
needs
âĨ 2
symptoms (must got âĨ 1 of the symp. fr Major)
and
Minor criteria
Facial pain/pressure
Hyposmia or Anosmia
Major criteria
Rhinorrhea/Postnasal drip
Nasal blockage
PE
via
Endoscopy
look inside nasal cavity
and/or
āļĢāļīāļāļŠāļĩāļāļ§āļāļāļĄāļđāļ (Nasal polyp )
D/C āļĄāļđāļāļāļāļŦāļāļāļ fr Middle meatus
Mucosa around Middle meatus swelling or obstructed
CT scan
Thickening of epithelium lining inside osteomeatal complexm and/or within sinus
Child
criteria (EPOS2012)
Symptoms
Needs âĨ 2 symptoms in which one of the these need to be Major criteria
Minor
Facial pain/pressure
Cough
(differ fr Hypo/Anosmia in Adult)
Major
Nasal blockage
Rhinorrhea/Postnasal drip
PE
via
Endoscopy
look inside nasal cavity
and/or
āļĢāļīāļāļŠāļĩāļāļ§āļāļāļĄāļđāļ (Nasal polyp )
D/C āļĄāļđāļāļāļāļŦāļāļāļ fr Middle meatus
Mucosa around Middle meatus swelling or obstructed
CT scan
Thickening of epithelium lining inside osteomeatal complexm and/or within sinus
Acute vs Chronic
Acute Rhinosinusitis
Acute viral rhinosinusitis/Common cold
Acuten Post-viral rhinosinusitis
Acute bacterial rhinisinusitis
Chronic Rhinosinusitis
Def: > 12 wks
Classification
into
CRS
with
nasal polyp
Check nasal cavity found
Nasal polyp at Middle meatus
CRS
without
nasal polyp
Check nasal cavity canât see nasal polyp in Middle meatus
:gear:
PathoPSO
:fire:
Complication
:fish_cake:Complication that affect Lower & Upper Respiratory epithelium
:fish_cake:Orbital com using
Chandlerâs classification
Endocranial artery comp
Osseous comp