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Table 3.9 It is showing local complication list, clinical features, and management

Complications Clinical features Management Mucocele Can present as swelling in and around the eye (ethmoid and

Pott’s puffy tumor

Facial cellulitis and abscess

frontal mucocele) or just some pressure symptoms or orbital symptoms (sphenoid mucocele)

Frontal sinusitis with acute osteomyelitis. Subperiosteal pus collection in the frontal sinus leads to puffy uctuance.

• Patient presents with fever, headache, neurological ndings, periorbital/frontal swelling, nasal congestion, and rhinorrhea.

•

May be associated with other abscess like pericranial,

periorbital, epidural, subdural, and intracranial abscess if not managed adequately.

Fronto- cutaneous stula as a late complication.

•

• CT Scan imaging modality of choice.

These complications are local complications associated with acute sinusitis especially of the ethmoids and maxillary sinusitis.

Endoscopic clearance or external approach

Managed by combined neurosurgical and ENT team.

Managed by aggressive antimicrobial therapy followed by surgery to clear the pus and open the sinuses.

K. Davraj et al.

Fig. 3.12 Left side frontal mucocele. The left eyeball is pushed inferomedially and radiology is correlating with clinical photograph (Courtesy—Dr. Hitesh Verma, Associate Professor, AIIMS, New Delhi, India)

orbit very rapidly. They are given as Chandler’s criteria [42] (i) Preseptal cellulitis (Fig.3.13) (ii) Orbital cellulitis (Fig.3.14) (iii) Subperiosteal abscess (Fig.3.15) (iv) Orbital abscess (v) Cavernous sinus thrombosis (Fig.3.16)

[43–46]

Intracranial infection due to sinusitis occurs either due to direct extension of infection or through hematogenous spread. Direct extension occurs due to either sinus wall erosion or through fracture lines or neurovascular foramina. Hematogenous spread on the other hand is

Fig. 3.13 Right side preseptal cellulitis with facial cellulitis

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Table 3.10 It is showing the type of orbital complications, Symptomatology, and treatment

Orbital

compli cations Symptomatology Treatment [41]

Immediate i.v antibiotics, warm compress, and

Preseptal cellulitis

Orbital cellulitis

Subperi osteal abscess

Orbital abscess

Cavernous sinus thrombosis

• Eyelid edema and erythema Extraocular movement intact

•

Normal vision May have eyelid abscess

•

CT Scan: Diffuse thickness and edema of

lids and conjunctiva

• Least severe, most frequent Post septal infection

•

Eyelid edema/erythema Proptosis and chemosis

•

Impaired Extra ocular movt.

• No discrete abscess

• Visual acuity intact CT shows low attenuation adjacent to

•

lamina papyracea

•

Pus formation between periorbita and lamina

papyracea

• Displace orbital contents downward and

laterally

Proptosis, chemosis, ophthalmoplegia

•

• Risk for residual visual sequelae

• May rupture through septum and present in

eyelids

• CT Scan: Rim enhancing hypodensity with

mass effect adjacent to lamina papyracea

• Pus formation within orbital tissues

• Severe exophthalmos and chemosis

• Ophthalmoplegia

• Visual impairment

• Risk for irreversible blindness

• Can spontaneously drain through eyelid

• Orbital pain

• Proptosis and chemosis

• Ophthalmoplegia

• Symptoms in contralateral eye

• Associated with sepsis and meningismus

• Radiology: Poor venous enhancement on

CT.Better visualized on MRI

• head elevation

• Facilitate sinus drainage using nasal decongestants, mucolytics, and saline nasal douching.

•

Immediate i.v antibiotics, warm compress, and

head elevation

• Facilitate sinus drainage using nasal decongestants, mucolytics, and saline nasal douching

Surgical intervention to facilitate sinus drainage if

• symptoms worsen in 48h.

• This could be done either endoscopic or external approach

•

Medical and surgical management

• Look for worsening of visual acuity and EOM movements

Surgical drainage by doing external

• ethmoidectomy (Lynch Operation). Remove

lamina papyracea

• Endoscopic approach for medially placed abscesses

• Transcaruncular approach

(transconjunctival incision extend medially around lacrimal carbuncle)

Drain sinuses and abscess

•

• Incise periorbita and drain the intraconal abscess

• Similar approaches as with subperiosteal

• Abscess (Lynch incision, Endoscopic for medial extent)

• Condition is very serious and warrants immediate attention

I.V Antibiotics which cross blood-brain barrier in

• high doses

•

Surgical drainage of sinuses

• Mortality can be as high as 30%

Anticoagulant use to stop further propagation of

• clot is controversial.

through the diploic skull veins or through vessels in the ethmoid bone. Thrombophlebitis originating in the mucosal veins progressively involves the emissary veins of the skull, the dural venous sinuses, the subdural veins, and, nally, the cerebral veins. By this mode, the subdural space may be selectively infected without contamination of the intermediary structure; a subdural empyema can exist without evidence of extradural infection or osteomyelitis. Intracranial infections are (Table3.11)

(i) Meningitis (ii) Epidural abscess (iii) Subdural abscess (iv) Intracerebral abscess (v) Cavernous sinus, venous sinus

thrombosis

Intracranial involvement usually presents with common symptomatology of fever, headache, nausea, and vomiting, seizures, altered sensorium, hemiparesis, visual disturbance, and meningismus.

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Fig. 3.14 NCCT PNS orbit is showing left side orbital cellulitis

K. Davraj et al.

Fig. 3.15 NCCT PNS orbit is showing right side subperiosteal abscess (Courtesy—Dr. Hitesh Verma, Associate Professor, AIIMS, New Delhi, India)

Fig. 3.16 Left cavernous sinus thrombosis (chemosis with dilated xed pupil and restriction of extraocular movements) (Courtesy—Dr. Hitesh Verma, Associate Professor, AIIMS, New Delhi, India)

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Table 3.11 It is showing the type of intracranial complications, clinical features, and management

Intracranial complications Symptomatology Treatment

•

Meningitis •

Epidural abscess

Subdural Abscess

Intracerebral abscess

Venous Sinus thrombosis

Most intracranial common complication Headache

• Meningismus

•

Fever Cranial nerve palsies

•

Kernig’s and Brudzinski sign (neck rigidity) Usually due to involvement of sphenoid and

•

ethmoid sinus

• Second most common complication Fever, headache, nausea and vomiting,

•

papilledema, hemiparesis, seizures

• Usual sinus involved: Frontal

• CT: Crescent hypodensity

• Third most common complication. Condition of

the patient deteriorates very rapidly leading to high mortality rates of residual neurological sequeal.

•

Headaches

• Fever

• Nausea, vomiting

• Hemiparesis

• Lethargy, coma

• Least common complication

• Generally due to frontal sinus involvement

followed by ethmoid and sphenoid sinus

• Headache Altered sensorium

•

• Focal neurological decit

• Fever

• Seizure, meningismus, papilledema

• 60% chance of neurological sequeal and high

mortality (20–30%)

Retrograde thrombophlebitis from the frontal

•

sinus may lead to thrombosis of the superior sagittal sinus.

• Can be associated with other intracranial

abscesses

• MRI: Decreased cavernous carotid artery ow

void

Mortality rate is high

•

Initially treated with antibiotics that

penetrates blood-brain barrier

• Followed by surgical drainage of the sinus

• Good antibiotic coverage for long duration (may range for 4–6weeks)

• Neurosurgical intervention for drainage of abscess

• Followed by ENT intervention of frontal sinus drainage (trephine, cranialization) or drainage of other involved sinuses.

Aggressive medical therapy

•

• Antibiotics

• Anticonvulsants

• Hyperventilation, mannitol, steroids

• Drain sinuses and abscess

• Medical therapy possible if <1.5cm

• Craniotomy or stereotactic burr hole

• Endoscopic or external sinus drainage

•

Aggressive medical therapy

• Antibiotics

Anticonvulsants

•

• Hyperventilation, mannitol, Steroids

• Drain sinuses and abscess

• Medical therapy possible if abscess <2.5cm

• Excision or aspiration

• Diagnostic aspiration if <2.5cm or cerebritis

• Stereotactic-guided aspiration

• Endoscopic or external sinus drainage

• Antibiotics, steroids, anticonvulsants

• Anticoagulation

• Drain source of infection the sinuses

3.5.3 Conclusion

Complications of sinusitis have come down drastically due to timely intervention with adequate antibiotics. Complications of sinusitis can be min-

imal but if not addressed on time, may become potentially fatal. If these complications worsen further immediate surgical attention using endoscopic or external approach has helped reducing the mortality following these complications.

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K. Davraj et al.

3.6 Part F: Allergic Rhinitis

3.6.1 Introduction

Allergy is a common disease the Indian incidence of which is 25–30%. In some countries, the incidence is as high as 40% of the general population, especially in young children. Though it can affects person of any age, it is generally a disease of the young. Children and adults of productive age are the common sufferers. Allergy is quite secular in affecting people of any race and of any geographical region. Women and men are both affected by allergies. Barring cardiovascular diseases and diabetes mellitus which are common ailments of older people, allergy is by far the commonest non-infective disease especially of the young. It is IgEmediated signifying that the affected person produces IgE class of antibodies in excess to the normal range of it. The antibodies will be specic to the causative allergen. An individual with such a status is referred to be an atopic person. Allergy cuts across the entire system of human organism and can affect any part of the body but it generally affects the skin, and the mucous membrane of respiratory system and gastrointestinal system. When it affects the skin, common clinical conditions that manifest are Urticaria, Angioedema, and Atopic Dermatitis. When it affects the respiratory system, it causes Rhinitis, Conjunctivitis, Sinusitis, Serous Otitis Media, and Asthma. Nose being the main door to the respiratory system bears the brunt of allergic onslaught and so Allergic rhinitis is the most common manifestation of atopic allergy.

Allergic Rhinitis (AR) is the most common manifestation of atopic allergy. When the disease is persistent and when the symptoms are moderate and or severe, AR causes a considerable morbidity in the patient, especially when the patient is a young child or an adult of productive age. AR can affect all the vital functions of the nose. AR must be diagnosed clinically and specically. Patients of AR must be treated adequately to provide relief of suffering, to prevent the development of complications, to reduce the suffering due to comorbidities and to prevent poly-sensitization.

John Bostock discovered AR when he presented an interesting case to the Medical and

Chirurgical Society on 16 March 1819 “Case of a periodical affection of the eyes and chest,” the rst recorded description of what he later called “catarrhus aestivus” or summer catarrh, and which soon became known as hay fever [47, 48].

IgE-mediated allergy is a very common disease affecting a signicant component of the general population. Children and adults in productive age are the common sufferers. Irrespective of the race and geographic distribution, the incidence of allergy is very high. Allergy cuts across the entire system of human organism and can affect any organ or any tissue but it generally affects the skin and mucous membrane of respiratory system and that of the gastrointestinal system.

Among different clinical manifestations of allergy, allergy affecting the respiratory system is the most common ailment. Nose being the main door to the respiratory system bears the brunt of allergic insult. In other words, allergy affecting the nose or AR happens to be the most common manifestation of allergy. Russel Settipane reports that 42% of Americans suffer from AR.AR has an estimated worldwide prevalence of 10–25% and is one of the most common diseases in childhood with a prevalence reaching up to 40% in some regions [49, 50]. In the year 2000, more than US$ 6 billion were spent on prescription medications for this condition [50, 51]. An estimated 14.1 million visits to a physician ofce are attributed to AR in the USA each year [52].

When the disease is persistent and when the symptoms are also of moderate or of severe degree, there will be a signicant impact on the quality of life of the sufferer. Normal daily activities get hindered. Work and School activities are affected. Sleeplessness and tiredness result in lowering of learning and cognitive functions. All these may result in an embarrassing situation for a growing child.

AR is unfortunately undertreated and is ignored to a large extent causing the disease to cascade to neighboring tissues like conjunctiva, paranasal sinuses, middle ear, and then to the lower airways. AR is caused by many aeroallergens like tree, weed, and grass pollen; cat, dog, house dust mite (HDM), and molds. HDM is the most common indoor allergen causing perennial AR [47, 53].

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Symptoms of AR appear on exposure to the causative allergens and triggers. Attempt must be made to avoid exposure to the causative allergens. However, objective evidence of raised serum specic IgE (ssIgE) to an inhalant aeroallergen is essential before a patient spends time and money for extensive allergen avoidance measures. In UK general practice, diagnosis by history alone resulted in false-positive identication of allergen triggers of 32% for cat allergy, 48% for grass pollen, 75% for HDM, 54% for tree pollen, and 27% for dog when compared with formal allergy assessment including skin prick test (SPT). There is no value in extensive HDM avoidance or removal of a family pet if the sufferer is non-atopic and has no relevant allergic sensitivities [54]. Thus, objective assessment of IgE sensitivity improves accuracy in identifying allergenic triggers and accurate diagnosis [55].

Furthermore, once ssIgE to an inhalant allergen is detected, the test must be interpreted correctly, and the clinician must distinguish between sensitization and allergy. At least 15% of people with a positive skin test do not develop symptoms on exposure to the relevant allergen, so the clinical history must be consistent with skin tests to conrm a clinically relevant sensitivity. For example, if a patient has year-round symptoms, severe rhinosinusitis, and nasal polyps, an isolated positive skin test to birch pollen is almost certainly irrelevant. However, they have a high negative predictive value, and therefore a patient with a negative skin prick test or no evidence of raised ssIgE is likely to be genuinely non-allergic.

3.6.2 Clinical Manifestations

andDierential Diagnosis

Following are the main or primary symptoms of AR:

• Sneezing

• Rhinorrhea

• Nasal Obstruction

Following are the associated symptoms of AR:

• Pruritus

• Nasal Intonation

Slight to moderate difculty in hearing due to

• inammation spreading to the Eustachian tube and sometimes into the middle ear

• Heaviness in the Head due to sinuses getting blocked

• Lack of Concentration

• Lack of Interest in Normal Social Activity

• Mouth Breathing due to Nasal Obstruction

• Anosmia due to Inammation affecting the Olfactory Nerve Endings

The complexity of symptoms could be a com-

bination of several of these symptoms and can vary differently in different cases.

I. Sneezing in AR is the most common symp-

tom. Sneezing can vary from one or two to as many as hundreds in a day. There are a few conditions mimicking AR. Every case of sneezing need not be of AR.Acute infective rhinitis, which is due to rhinovirus infection, would be of very recent origin. Accompanying symptoms of infection like fever, malaise, and signs of infective inammation of the mucosa will be present. Eosinophilic nonallergic rhinitis and Nasal mastocytosis are two other conditions simulating AR but are non-atopic. The incidence of these two conditions has not been documented in India. A revision documentation of history and absence of positive correlating skin prick test will assist the diagnosis of these two conditions. Cytology of nasal secretions will reveal the preponderance of eosinophils in eosinophilic non-allergic rhinitis and of mast cells in nasal mastocytosis.

II. Rhinorrhea in AR can be mild to very severe

and in severe cases, it can cause general weakness with lack of interest in either studies or at professional and social activities. The discharge, unless complicated by an infection, is thin and watery. Vasomotor Rhinitis (VMR) is the only other condition that mimics AR and is not uncommon in young women. In VMR, Rhinorrhea and Obstruction are commonly present, and sneezing is generally absent. Trivial stimuli like spicy food, odors, changes in temperature and humidity, sexual arousal, defecation, etc.

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K. Davraj et al.

may act as triggers to produce the symptoms. Similar symptoms may be produced in some cases due to other systemic drugs like some antihypertensive and hormonal medication. The absence of supportive information on nasal cytology and SPT for allergy will help the diagnosis. Very rarely though, VMR may be present concomitantly with AR when it is quite a challenge for the patient and to the doctor treating the case. Cerebrospinal uid (CSF) rhinorrhea is a rare condition that can be mistaken for the rhinorrhea of AR.History of trauma and injury to the skull must make a clinician to suspect CSF rhinorrhea. Do consider a congenital defect as a point of differential diagnosis in a very young child for CSF rhinorrhea.

III. Nasal obstruction is the third major com-

plaint in AR.A Large number of patients nd it difcult to cope up with this complaint when its severity is moderate or more than moderate degree. Children nd it very difcult to cope up with the nasal obstruction. It is due to the swollen mucosa, which is the result of the late phase of allergic inammation. There is a play of chemical mediators during the late phase. In addition to Histamine which is a pleiotropic mediator, cysteinyl leukotrienes, prostaglandins and Kinins are the other mediators that cause the late phase. Obstruction is usually unilateral and shifts from one side of the nose to the other every 4–6h depending on the secretory activity of the nose. In some cases, the obstruction can become bilateral and almost complete when the sufferer will be in a miserable condition. If there is a marginally deected septum also, the obstruction could be more on that side of the nose. Complete nasal obstruction results in the patient to become a mouth breather and if not treated early and adequately, it can affect the normal contour of a growing child’s face.

Unilateral obstruction can be due to a deviated nasal septum. Very rarely a “S” shaped crooked deection of the septum can cause bilateral

obstruction. Polyps can cause unilateral and bilateral obstruction. Sometimes they are concomitantly present with AR.Ethmoid polyps are commonly associated with AR.A foreign body and a tumor are other causes of unilateral obstruction. Bilateral obstruction may be due to Rhinitis Medicamentosa, which results due to the misuse of locally applied alpha-adrenergic drugs. History of obstruction in elderly patients must make the clinician to suspect atrophic rhinitis. Examination will reveal atrophic changes of the turbinates with crusts. These days it is not uncommon to encounter atrophic rhinitis among youngsters also, especially after surgical procedures in the nose.

Pruritus in AR is a common symptom. Itching of the eyes and in inner canthi with increased tears, itching in the nose and sometimes in the ears may be present. Itching of the palate is not uncommon and can be intense. It can be so intense in some patients that they try to scratch the palatal region with a spoon attempting to obtain relief of itching.

Nasal intonation is another associated symptom commonly present when the obstruction is profound either because of allergic inammation or when complicated by the presence of polyps.

3.6.3 Cascading Inammation ofAR

Causing Complications andComorbidities

It is quite common in many cases for AR to be concomitant with conjunctivitis. Eyes are exposed to the airborne allergens as much as the nose is. Anatomically the nose is better protected than the eyes. From another point of view, eyes have their lids to close and protect themselves which the poor nose does not possess. Though there is a difference in their structure and their physiology, they are neighbors to contend with. They are in close proximity and they are internally connected to each other through the nasolacrimal duct on either side. Tears are constantly produced in the eyes to irrigate and keep the eyes moist.

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Allergic inammation when present, cascades between the nose and the eyes conveniently to each other through the connecting nasolacrimal duct. That is how many cases of AR are cases of Allergic Rhinoconjunctivitis.

Paranasal sinuses are in close proximity to the nose. Mucous membrane in the nose and that in the paranasal sinuses is the same. In other words, there is a continuity of the same mucosa from the nose into the paranasal sinuses. Secretion from the sinuses gets drained into the nasal chambers through the ostium of each sinus. Even when the sinuses are not inamed with allergy, inammation of AR may and can occlude the ostium of these sinuses causing retention of uid in the sinuses. Retention causes heaviness in the head. The heaviness or fullness in the head may result in an unpleasant status and it leads to lack of concentration in studies and at work. Cavities as they are, the sinuses normally lighten the weight of the skull being borne by the neck. Sinuses also provide resonance to the voice. When they are blocked, both of these are affected. Further, the allergic inammation can spread to the sinuses causing sinusitis.

Inammation of AR can spread to the middle ear through the eustachian tubes causing allergic otitis media with effusion or Glue Ear. This is especially possible when AR is inadequately treated or when it is ignored. There will be loss of hearing in speech frequency. Loss of hearing can be mild to moderate. The affected person will have a feeling of fullness in the affected ear. Tinnitus can be present. When a young child develops glue ear, it can lead to a very bad disability for the child not developing proper speech and developing improper intellectual growth. It is important to identify and diagnose this condition as early as possible. Reparative measures must be instituted quickly and aggressively.

Anosmia is possible to occur when AR is illtreated or inadequately treated. It is clearly related to the disease duration and severity. Persistent inammation and its effect on the umbrella of innumerable nerve endings of the olfactory nerve cause this damage. Loss of smell can be considered in children, as in adults, to be a

clinical marker of disease severity [32]. This complication of AR needs a quick and detailed attention since the loss of olfaction will lead to several obstacles in a growing child’s development. Loss of smell causes loss of perceiving the aroma of food which in turn results in loss of appetite and further non-secretion of saliva and other enzymes, leading to difculty in digesting food. It may further result in nutritional deciency which will stunt the growth of the affected child.

When allergy cascades downwards, it affects the pharynx causing pharyngitis with symptoms of the sore throat sometimes associated with slight difculty in swallowing and a constant urge to clear the throat.

Further down when it affects the larynx, it causes laryngitis with loss of range of voice, hoarseness of voice, and loss of timbre of voice.

As it cascades further downwards, it causes comorbidity in the trachea causing tracheitis or cough variant asthma with dry cough, sometimes a very annoying difculty to the patient especially at nights.

Bronchial asthma is the resultant condition when allergy invades the lower airways. Episodes of cough, tightness of chest, wheeze, and breathlessness which can be of varying degree are the symptoms. Signicant limitation to the life of a patient happens when the disease is persistent and when the symptoms are moderate or more than moderate.

When these conditions persists, they become comorbidities. These are actually complications of AR especially when it is neglected or if AR is not treated adequately. Conjunctivitis, Sinusitis, and Asthma could be comorbidities right from the onset of AR in a few cases. Further Inquiry, Classication of the Disease and Clinical Findings on examination (Fig.3.17):

Even before you examine a patient of suspected AR, history would be quite revealing in most of the cases. Depending on the episodes and severity of the symptoms, a patient can be classied into one of the four groups. This guidance is very helpful in making a strategy for treatment.

Anterior rhinoscopy will reveal pale, swollen mucosa with rugosity and it will be boggy

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Intermittent symptoms

< 4 days/ week or < 4 per episode

Mild symptoms

• Normal sleep

• Normal working & normal school activity

• Normal daily activity

• No disturbing symptom

Fig. 3.17 Classication of the Disease on the basis of duration and interference in daily activities [56]

both over the septum and the turbinates. Clear transudate will be present in uncomplicated cases. The diagnostic endoscopic examination will conrm the picture of AR as also of any other comorbidity like a deected septum and a complication like polyps, adhesions, synechiae, perforations, atrophic changes; and presence of a tumor or a foreign body. It will also provide a picture of the nasopharynx and condition of the ostia of paranasal sinuses, especially of the maxillary sinus. A telescope of 0o or a 30o and with a wide-angle prole provides adequate endoscopic examination.

When necessary, the nasal secretion can be examined for the type of cells present. To get a good columnar epithelial cell sampling, a small sterile cotton-tipped applicator can be passed under the interior turbinate and gently rubbed along the oor of the nose and is then rolled onto a clean glass slide. The procedure is done under direct vision. It may either be xed with spray-x for a later study or can be stained with

Persistent symptoms

≥ 4 days/ week &≥ 4 weeks/ episode

Moderate to severe symptoms (one or more points valid)

• Disturbed sleep

• Working & school activity at problem

• Impairment of daily activity

• Disturbing symptom

The existence of an entity called local allergic rhinitis (LAR) with nasal production of specic IgE (sIgE) antibodies in the absence of atopy, in over 40% of non-allergic rhinitis (NAR) patients has been reported [57]. Evidence for this entity is supported by the clinical symptoms, the local production of sIgE, and a leukocyte-lymphocyte inammatory pattern, with an increase in the nasal uids of eosinophils, mast cells, and T lymphocytes during natural exposure to aeroallergens, as well as a positive immediate and dual response to a nasal allergen provocation test (NAPT) with local production of tryptase and eosinophil cationic protein and an increase of nasal sIgE to inhalant allergens [37]. Over recent years, increasing evidence has shown that an important number of patients previously diagnosed with NAR or idiopathic rhinitis develop a local allergy with nasal production of sIgE and a positive response to a NAPT [57]. This entity has been suggested to be entopy or LAR. These patients could also progress over time to AR [57].

Gram’s stain or Papanicolaou stain immediately for the study. Epithelial cells, granulocytes, and mononuclear cells are looked for, and presence of bacteria is also observed. These cytograms

3.6.4 Management ofAR:

Therapeutic Options (Fig.3.18)

can be of substantial help in diagnosing AR or to rule it out.

Nasal obstruction can be measured using a Rhino-manometer. It provides a measure of the nasal airway resistance present in a given case at a given time. The procedure uses a pneumotachograph to measure the ow of air through the nose.

Unless the disease is mild, AR must not be taken for granted. It must be treated adequately. Patient must be convinced of the need to treat the inammatory disease properly.

Allergen avoidance is easy said than done. Once the causative allergens are found and if avoidance is possible, it is the best course of

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Fig. 3.18 ARIA Guidelines

Allergen avidance

indicated when

possible

pharmacotherapy

safety

effectiveness

easily

administered

Table 3.12 Effect of treatment on symptoms [58]

Sneezing Rhinorrhea Obstruction Itching Eye symptoms

H 1-antihistamincs

•

Oral ++ ++ + +++ ++ Intranasal ++ ++ + ++ 0

• intra-ocular 0 0 0 0 +++

•

Corticosteroid

•

Intranasal +++ +++ +++ ++ ++ Oral +++ +++ +++ +++ +++

•

Chromones

•

Intranasal + + + + 0

• Intra-ocular 0 0 0 0 ++

Decongestants

• Intranasal 0 0 +++ 0 0

• Oral 0 0 + 0 0

Anti-cholinergics 0 ++ 0 0 0 Anti-leukotrienes 0 ++ + 0 ++

ARIA

guideline

Patient education

always indicated

immunotherapy

effectiveness

prescription may

alter the natural

course of the

specialist

disease

action. For pet allergens and for some food allergens, avoidance can practically be the complete solution.

A variety of molecules are available to treat and address different symptoms of AR.Depending on the severity of symptoms and morbidity, the medication must be chosen (Table3.12).

When AR is mild, H1 blocker, an antihistamine of the new generation can address all the

symptoms. First Generation antihistamines have been discarded because of the profound drowsiness they cause. New generation antihistamines provide good relief and can relieve comorbid symptoms also. Good compliance is possible because of once-a-day dosage. Several of these molecules do not cause drowsiness. There is an array of new generation molecules that have superior therapeutic exertion and a good safety

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