1	Treatment of Rhinitis & Sinusitis Kevin T. Kavanagh, M.D., F.A.C.S.
2	Types of Rhinitis ( Inflammation of the Nose ) Acute Rhinitis Vasomotor Rhinitis Intrinsic or Hyperplastic Rhinitis Allergic Rhinitis
3	Symptoms Nasal (Nose) Obstruction Nasal (Nose) Drainage--Type Itchy Watery Eyes Facial Pressure & Pain Sneezing Asthma
4	Acute Rhinitis Febrile, Purulent Nasal Drainage Allergy Tests Negative IgE Negative Family History Positive (Every One Gets This)
5	Acute Sinusitis – “Cold” Pathogens. Haemophilus influenzae Streptococcus pyogenes Streptococcus pneumonia Anaerobic Organisms
6	Chronic & Recurrent Sinusitis Treat with antibiotics for three to four weeks. High incidence of b-Lactamase producing bacteria. Augmentin Ceftin Clindamycin Cipro Moisturizer & Decongestant. Do not use an antihistamine--Dryness.
7	Vasomotor Rhinitis Afebrile, Clear Nasal Drainage Allergy Tests Negative IgE Negative Family History Negative
8	Vasomotor Rhinitis - Treatment Astelin Nasal Spray has been shown to be effective Antihistimines and nasal steroids do not give symptomatic relief in most patients.
9	Hyperplastic Rhinitis Hyperplastic Rhinitis is also known as: Intrinsic Rhinitis Eosinophilic Nonallergic Rhinitis Allergic Fungal Sinusitis
10	Hyperplastic Rhinitis Afebrile, Clear Nasal Drainage, Polyps Allergy Tests Negative IgE Positive Family History Positive
11	Hyperplastic Rhinitis Treatment Surgical debridement of obstructed sinuses to remove fungal debris. Sporonox. Antifungal Nasal Washes. Intranasal steroids
12	Allergic Rhinitis Afebrile, Clear Nasal Drainage, May Have Polyps Allergy Tests Positive IgE Positive Family History Positive
13	Allergic Rhinitis: Symptoms Seasonal Symptoms: Pollen Bluegrass, Timothy, Ragweed Perennial Symptoms: Household allergens dust mites, molds, feathers, animal dander. Sensitive to Chemical Irritants:
14	Allergic Rhinitis – Aspirin Triad Aspirin Triad Nasal Polyposis Allergic Sinusitis Asthma
15	Allergic Rhinitis: Seasonal Ideal for medical therapy Antihistamines/ Decongestants Nasal Steroids Cromolyn Sodium Singular Allergy Desensitization
16	Allergic Rhinitis: Perennial Animals outside. No Smoking in the house. Molds are found in: Houseplants Basements Showers Humidifiers (also increases house mites) Minimize use of rugs.
17	Perennial Symptoms House Mites (fecal allergen): Live off of skin flakes Wash bed linen in 140^oH₂O Water bed and plastic pillow liner Also some products will kill the mites or denature the fecal allergen. Electric HEPA Air Filters.
18	Smoker’s Rhinitis Chronic Rhinitis Resistant to medications and surgery. Hypertonic saline rinses help. Quitting smoking may worsen symptoms if goblet cell activity and secretions recover without recovery in cilliary clearance.
19	Medical Treatment
20	Decongestants Good for use in a “Cold” & Allergy Improves Airway. Does not improve, Nasal Drainage, Itching or Sneezing.
21	Decongestants-Complications Do not use in hypertensive patients or patients with a cardiac arrhythmia. Makes no sense to be on Beta-Blockers and then give the patient a decongestant. Diabetics--Decreases insulin requirements. Taking MAO Inhibitors or Antiparkinson medications.
22	Moisturizers Use in “Cold” or URI Robitussin Entex LA
23	Antihistamines-Complications Drys Secretions--Do not want to use in a URI. Sedation. Urinary Retention. Impotence.
24	Antihistamines-Nonsedating Zyrtec (Cetirizine)--some patients experience mild sedation. Once a day dosage. May use in Asthmatic Patients. Works on both early and late phase reactions. No hepatic metabolism, thus no adaptation.
25	Antihistamines-Nonsedating Allegra (fexofenadine)--no anticholinergic effects. Twice a day dosage. Use in asthmatic patients. Use in patients with prostratic hypertrophy. No sedative effects. No anticholinergic, antidopaminergic or alpha-adrenergic effects.
26	Antihistamines-Nonsedating First Non-sedating antihistamine to be available over the counter. Claritin (Loratadine)--many studies indicate this is a weak antihistamine but is now available over the counter. However, it is now available over the counter and can be obtained by patients without a prescription. Has sedative effects in higher doses.
27	Zyrtec vs. Claritin
28	Claritin vs. Chlorpheniramine
29	Antihistamines-Nonsedating Astelin (Azelastine)--Nose spray & Oral Inhibits secretions, serotonin, leukotrienes, and histamine. Bad Taste & Mild Sedation in Oral Forms.
30	Intranasal Sprays Decongestants--Only a short course in acute rhinitis or sinusitis. Cromolyn Sodium--Only in Allergic Rhinitis. Antihistamine. Anticholinergic. Steroid--Better long term efficacy than Cromolyn Sodium.
31	Rhinitis Medicamentosa Chronic Nose Spray Use--Over 5 or more days Treatment: Use Intranasal Steroid--Vancenase or Beconase (Patients like TID dosage)
32	Nose Spray: Cromolyn Sodium Reduces degranulation of Mast cells. Best results if started before pollen exposure. Very Safe. Used in patients with mucosal thinning or bleeding. Ideally should be used six times a day. Over the counter drug.
33	Nose Spray: Anticholinergic Atrovent Nasal Spray: Use to Dry Secretions and Nasal Drainage. Use in Vasomotor Rhinitis and Allergic Rhinitis. DO NOT USE IN ASTHMA
34	Nose Spray: Steroid Will improve Asthma: (Bronchial steroids are first line of treatment for asthma.) May cause septal perforation--especially if prior nasal surgery. Monitor patient every three months. Nasonex: Is reported to have little if any propensity to thin the nasal mucosa.
35	Nasal Septal Perforation Symptoms Include: Whistling, bleeding, collapse of nose and crusting. Treatment: Moisturizers, septal button, surgical closure. Surgical closure has a high failure rate.
36	Intranasal Steroids in Children Flonase FDA approved for use ages 4 and older. Has low systemic blood levels. Beconase, Vancenase, Rhinocort, Nasacort FDA approved age 6 yrs and older. Nasonex FDA approved for use age 12 and older. Has the lowest systemic blood levels Although some clinicians use them in younger children with close follow-up.
37	Nasosteroids - Bioavailability The nasal steroids with the least bioavailability are Nasonex and Flonase. These steroids should probably be the first choice in children.
38	Allergy Testing Prick Testing Well Tolerated Not as accurate, cannot be on Beta Blockers Skin End Point Titration Gold Standard Uncomfortable, cannot be on Beta Blockers RAST Testing Good for children, can be on Beta Blockers Not as accurate as SET. Not covered by third party payers
39	Allergy Testing-Prick & SET Patients have to be off of all antihistamines for 4 days. Off of non-sedative antihistamines for up to 6 weeks. Cannot be on Beta Blockers.
40	Food Allergies-Types IgE: Very Severe, do not desensitize or skin test these patients. IgG: Most Food Allergies are these. Will not be detected by Skin or RAST testing (IgE). All Foods are digested thus the substance tested for may not be the allergen produced from the food.
41	Food Allergies Skin Testing. Only Tests for IgE allergies. Thus, unlikely to be useful in detecting food allergies. Oral Challenge Tests. Gold standard in food allergies. Medicare does not approve payments for food testing.
42	Types of Inhalation Allergies All year around – perennials house hold molds, dust mites, cat, dog etc. Seasonal - Pollens early spring – trees late spring – grasses Fall – weeds Rains makes worse – Molds Rains makes better – Pollens
43	Allergy Proof Your House Indoor molds grow anywhere it is wet. This includes, basements, bathrooms, garages, kitchens and around all plants. Getting a dehumidifier and replacing real plants with plastic plants will often help.
44	Allergy Proof Your House A house dust allergy is actually an allergy to fecal material to the dust mite. Taking out carpets and installing wooden or linoleum floors will help, especially in the bedroom where you spend the most time. A plastic cover over bedroom pillows and mattress will help to reduce exposure. Bed sheets and linens should be washed in hot water.
45	Allergy Proof Your House Keep animals outside. Do not sleep with your pets. HEPA filtered vacuum can also be helpful If your are allergic to outdoor antigens, keep the windows of your house down and install furnace filters, or a free-standing air filter, which will clean the allergens from your house.
46	Surgical Treatment Steriod Injection of Turbinate--Associated Blindness Turbinectomy Cryotherapy Endoscopic Sinus Surgery Septoplasty
47	Surgical Treatment
48	Surgical Treatment - Septoplasty
49	Red Flags: Unilateral Sinusitis Think Carcinoma: Inverting Papilloma, Squamous Cell Carcinoma, Angiofibroma
50	Cystic Fibrosis May or may not have nasal polyps. Any white child with nasal polyps has cystic fibrosis until proven otherwise. Almost all have pseudomonas as the bacterial pathogen. Order Sweat Chloride Test.
51	Immunologic Disorders Often has small or absent tonsils. Order--Immunoglobin Levels IgE, IgA, IgG, IgM, IgD and IgG Subclass. Pneumovac and check antibody levels. Mumps, Candida Skin Tests.