8/9/2012 1 Allergic Rhinitis Allergic Rhinitis Christine Hancock, R3 Christine Hancock, R3 Cycle 2 Ambulatory Chief Talk Cycle 2 Ambulatory Chief Talk Santa Rosa Family Medicine Residency Santa Rosa Family Medicine Residency August 9, 2012 August 9, 2012 Outline Outline Signs & Symptoms Signs & Symptoms Paroxysms of sneezing, rhinorrhea, Paroxysms of sneezing, rhinorrhea, nasal obstruction & postnasal nasal obstruction & postnasal drainage drainage Periorbital and conjunctival Periorbital and conjunctival erythema, infaorbital cyanosis erythema, infaorbital cyanosis Swollen, pale nasal turbinates with Swollen, pale nasal turbinates with dimpling dimpling “Allergic salute” “Allergic salute” Perennial vs seasonal Perennial vs seasonal Differential Diagnosis Differential Diagnosis URI (“infectious rhinitis”) URI (“infectious rhinitis”) Rhinitis 2/2 meds Rhinitis 2/2 meds Rhinitis medicamentosa Rhinitis medicamentosa Vasomotor rhinitis/NARES “non Vasomotor rhinitis/NARES “non- allergic rhinitis with eosinophilia allergic rhinitis with eosinophilia syndrome” syndrome” Congenital syphillis, CSF rhinorrhea, Congenital syphillis, CSF rhinorrhea, pregnancy, hypothyroidism pregnancy, hypothyroidism Aspirin Aspirin-induced asthma induced asthma
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8/9/2012
1
Allergic RhinitisAllergic RhinitisChristine Hancock, R3Christine Hancock, R3Cycle 2 Ambulatory Chief TalkCycle 2 Ambulatory Chief TalkSanta Rosa Family Medicine ResidencySanta Rosa Family Medicine ResidencyAugust 9, 2012August 9, 2012
OutlineOutline
Signs & SymptomsSigns & Symptoms
�� Paroxysms of sneezing, rhinorrhea, Paroxysms of sneezing, rhinorrhea, nasal obstruction & postnasal nasal obstruction & postnasal drainagedrainage
�� Periorbital and conjunctival Periorbital and conjunctival erythema, infaorbital cyanosiserythema, infaorbital cyanosis
�� Swollen, pale nasal turbinates with Swollen, pale nasal turbinates with dimplingdimpling
�� AnimalsAnimals: keep out of pts bedroom, keep in room : keep out of pts bedroom, keep in room w/ HEPA filter, use vacuum w/ HEPA filterw/ HEPA filter, use vacuum w/ HEPA filter
�� Outdoor allergensOutdoor allergens: close windows at home and in : close windows at home and in car, stay indoors, use AC to filter air, shower before car, stay indoors, use AC to filter air, shower before bed, dry laundry inside, wear glasses, rinse contacts, bed, dry laundry inside, wear glasses, rinse contacts, avoid windy days and mornings between 5avoid windy days and mornings between 5--10AM, 10AM, take meds 1 hour before heading outdoorstake meds 1 hour before heading outdoors
�� Use nasal rinses: make your own normal saline! Use nasal rinses: make your own normal saline! (SOR B)(SOR B)
�� 4 c (1 qt) of water, boiled for 5 min (?), plus4 c (1 qt) of water, boiled for 5 min (?), plus
�� 11⁄2 level tsp of table salt 11⁄2 level tsp of table salt -- (Brown & Graham 2004)(Brown & Graham 2004)
Pharmacologic TxPharmacologic Tx
1.1. Antihistamines (Antihistamines (diphenhydramine, loratadine, diphenhydramine, loratadine, cetirizine, fexofenadinecetirizine, fexofenadine): Often first line for ): Often first line for mild sxmild sx
2.2. Intranasal glucocorticoids (budesonide, Intranasal glucocorticoids (budesonide, fluticasone, etc.): Most effective, should be fluticasone, etc.): Most effective, should be first line if moderate to severe sxfirst line if moderate to severe sx
�� Start an inhaled corticosteroid, a second generation Start an inhaled corticosteroid, a second generation antihistamine, or bothantihistamine, or both
�� For resistant nasal sx, add a LTRA, for resistant other sx For resistant nasal sx, add a LTRA, for resistant other sx consider cromolyn or an ocular antihistamineconsider cromolyn or an ocular antihistamine
�� Start allergy shots if inadquate relief with meds or if Start allergy shots if inadquate relief with meds or if allergies are worsening asthma or sinusitis.allergies are worsening asthma or sinusitis.