Day Release 200109

1
Day Release 20/01/09

• Purandhar Nosina
• Westgate Medical Practice Dundee

2
Back Ground

• 47 yr old lady
• Long standing h/o allergic rhinitis for approx 9
  yrs.
• Long term sick leave due to symptoms
• Has been on nasal Steroids (fluticasone,
  mometasone), Antihistamines (topical
  azelastine, oral fexofenadine), and Topical
  sodium Cromoglycate.
• Current Rx Azelastine nasal spray BD, Flixonase
  spray two puffs OD, Fexofenadine 180mg OD.
• Been s/b ENT Dept., thoroughly investigated along
  with allergy tests (positive for house dust mite
  and pollen) CT head to r/o pathology in sinuses
• Eventually discharged with above recommended plan
  as drained of options.

3
Consultation

• Sept 08 - Attended with flare up of symptoms (
  severe nasal congestion, runny nose, sneezing).
• Tearful, and talked about the effect of current
  symptoms on daily life and at work.
• Very keen to work
• Long chat
• Negotiated plan
• Follow up in 2/52.

4
Follow Up

• Delighted
• Cut down INS
• Happy with the new Rx

5
Management

• Guidelines according to http//www.bsaci.org
  published in InnovAiT
• Informed about availability and web based
  resources for info.

British society for allergy and clinical
immunology
6
Check for ASTHMA Rx

• AVOID
• Sedating antihistamines
• Depot corticosteroids
• Chronic use of decongestants
• Or systemically bioavailable INS
• (e.g. Dexametha, Betamethasone)

RHINITIS Nasal congestion, Rhinorrhoea, Itching,
Sneezing
New polyps (gelatinous, insensitive - Unilat.
Symps signs
-History suggestive of allergy Itching, Sneezing,
conjunctivitis - Positive SPT or RAST
Systemically unwell (tired, Sleep apnoea, Rash,
Malaise etc)
Nasal crusting, Bleeding or Nasal deformity
No obvious cause
Thick, green Secretions
INFECTIVE RHINITIS/ SINUSITIS
ENT Referral
ALLERGIC RHINITIS
OTHER

• Consider
• Non allergic
• Autonomic (vasomotor)
• Hormonal
• Drug induced
• (decongestant overuse,
• Aspirin/NSAID
• sensitivity,
• Nasal polyps,
• Anti hypertensive

Allergen and irritant avoidance, where
appropriate, consider Douching
Orbital cellulitis
Nasal Douching /- INS
Mild Intermittent
Moderate severe/ Persistent affects QoL
ABX if severe Pain / Fever
Non sedating Anti histamine
Regular INS (non systemically bio available)
If Chronic/recurrent Consider allergy or Immune
deficiency
Poor response
Treat the underlying cause Course of INS could
be tried.
Combine above (AH INS)
Poor response
No Improvement
URGENT ENT
REFER TO ALLERGY CLINIC
7
Diagnosis by History /- SPT/Serum specific
IgE Allergen / irritant avoidance /- Douching
Algorithm for Rx of Rhinitis
mild
Symptoms
Oral/topical non sedating antihistamine
Moderate / severe
Topical nasal Steroid
Rx Failure
Rx Failure
Check use, compliance, ? dose, /- OC
Rx Failure
Blockage
Catarrh Add LTRA if asthmatic
Itch / sneeze Add non sedating antihistamine
Watery rhinorrhoea Add Ipratropium

• Add (briefly)
• Decongestant
• Or OC
• Or (long term long acting
• Non sedating antihistamine
• Topical Azelastine / LTRA)

Rx Failure
?infection / structural problem
Surgical referral
Consider Immunotherapy if symptoms predominantly
due to one allergen
SPT skin prick test, OC oral corticosteroids
8
Drugs available

• Oral Antihistamines preferably 2nd gen.
  (Loratidine, Fexofenadine)
• Intranasal Antihistamines Azelastine nasal spray
• Intranasal Steroids Fluticasone (flixonase),
  Mometasone (nasonex). Beclomethasone (Beconase
  spray), Betamethasone (betnesol drops),
  Budesonide (rhinocort).
• Topical Chromones Sodium cromoglycate (Vividrin
  nasal spray)
• Topical nasal Decongestants (Ephedrine nasal
  drops, Xylometazoline)
• Antimuscarinics Ipratropium bromide (Rinatec)
• Oral Corticosteroids 20 30mg/day
• Leukotriene receptor antagonists Montelukast
  (Singulair)
• Referral
• Unilateral symptoms, New nasal polyps, nasal
  crusting / bleeding, nasal deformity, Rx failure
  in primary care, for consideration of
  desensitisation (to allergy clinic)

9
Nasal Douching

• Benefits
• Moistens nasal passages
• Washes out mucous, bacteria, pollen dirt
• Reduces swollen congested nasal and sinus
  tissue
• Supports reactivates the function of the cilia
  
• Irrigations are simple to carry out
• Drug-free Safe for children and pregnant women
  

• Video http//uk.youtube.com/watch?v8EthvSkso2Q

10
Follow Up

• Still delighted
• Not needing any IN meds since Sept08
• Applying for jobs - hopeful
• Increase in confidence

11
Happy Nasal Douching