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Seasonal Allergic Rhinitis

A. Pathogenesis. Contact with the allergen leads to the production of IgE, which are fixed on the mast cells of the nasal mucosa. When allergens re-enter the nasal mucosa, mast cells degranulate and release inflammatory mediators - histamine, leukotrienes, prostaglandins, kinins, hydrolases (see Chap. 2). These substances cause vasodilation and increase their permeability, which leads to swelling of the mucosa and increased secretion of mucus. Chemotaxis factors stimulate the flow of eosinophils, neutrophils, basophils, monocytes and lymphocytes. Activated eosinophils release the main basic protein and cytotoxic mediators that are involved in mucosal damage.

B. The clinical picture

1. Typical manifestations of seasonal allergic rhinitis include swelling of the nasal mucosa, profuse watery discharge from the nose, sneezing and itching in the nose, which appear only when in contact with the allergen. Sometimes patients complain of a sore throat. Runoff of mucus on the back of the throat causes a dry cough, the voice becomes hoarse. Allergic rhinitis can be accompanied by headache, pain in the paranasal sinuses and nosebleeds.

2. Physical examination. With rhinoscopy, edematous pale pink or bluish-gray nasal concha are visible. Allocations are transparent. Mucosal edema sometimes leads to bulging of the lower wall of the nasal cavity.

a. Dark circles under the eyes appear, apparently, due to venous stasis caused by swelling of the nasal mucosa and sinuses.

b. Allergic salute is a gesture characteristic of children with allergic rhinitis. Trying to reduce itching and facilitate nasal breathing, patients rub the tip of the nose with their palms from the bottom up.

in. The transverse fold between the tip of the nose and the nose, a characteristic sign of allergic rhinitis, occurs due to the constant rubbing of the tip of the nose, usually appears no earlier than 2 years after the onset of the disease. It must be distinguished from the congenital transverse fold of the nose, a rare hereditary trait. The congenital transverse fold of the nose, unlike the acquired one, does not disappear with pressure on the tip of the nose from above.

Adenoid face - open mouth, dark circles under the eyes, sleepy facial expression. Allergic rhinitis that occurred in early childhood leads to impaired development of the facial section of the skull. Due to the fact that the child constantly breathes through the mouth, a Gothic palate is formed, an elongated, flat upper jaw, an underdeveloped chin and an incorrect bite.

The Denny Lines - folds under the lower eyelids - appear in early childhood. Characteristic for allergic rhinitis and diffuse neurodermatitis.

e. When examining the oropharynx, hypertrophic lymphatic follicles and drainage of the discharge along the posterior pharyngeal wall are visible.

g. Geographic language - sharply defined whitish spots on the surface of the tongue - is often found in allergic rhinitis. Less commonly observed is a folded tongue.

h. During a physical examination, complications of allergic rhinitis such as otitis media, sinusitis, and nasal polyps are necessarily excluded.

B. The diagnosis of seasonal allergic rhinitis is easy to make based on the history and physical examination. For the differential diagnosis of allergic rhinitis with vasomotor, infectious and eosinophilic non-allergic rhinitis (see table. 5.1) carry out the following studies.

1. The study of discharge from the nose. To get nasal discharge, the patient is asked to blow his nose in waxed paper or cellophane. Material for research can also be obtained using a thin stick wrapped in cotton wool, which is left in the nose for 2-3 minutes, or using a small rubber bulb. The resulting detachable is transferred to a glass slide and dried. The smear is stained according to Wright or Hansel and examined under a microscope. Accumulations of eosinophils are characteristic of seasonal allergic rhinitis, their relative number exceeds 10% of the total number of leukocytes. At the height of the flowering season, the number of eosinophils in a smear sometimes reaches 80–90%. The predominance of neutrophils in a smear indicates infectious rhinitis. To obtain samples of the epithelium of the nasal mucosa, use a disposable curette (see Appendix II).

2. General blood test. Moderate eosinophilia is often noted; the absolute number of eosinophils (see Appendix III) may exceed 700 μl – 1. Eosinophilia is more commonly observed during the flowering season of plants.

3. Determination of the total serum IgE level makes it possible to distinguish allergic rhinitis from non-allergic rhinitis. This indicator is determined using a radioimmunosorbent test (see Appendix IV) or solid-state ELISA. A significant increase in serum IgE is observed in approximately 60% of patients with bronchial asthma and allergic rhinitis. At the same time, other reasons for increasing the level of IgE, especially helminthiases, should be excluded. To assess the results, use the age norms adopted in this laboratory.

4. Allergen determination

a. Skin tests - puncture and scarification - are the best method for detecting an allergen that causes allergic rhinitis (see chap. 2, subparagraph II.V.4.v.1—2). Skin tests are highly specific, less often than intradermal tests, cause systemic allergic reactions and allow several allergens to be determined simultaneously. When examining children under 3 years of age, intradermal tests are usually performed, since skin reactivity at this age is reduced and skin tests are uninformative.

b. Intradermal tests are performed only after skinning in those cases when there is a negative or weakly positive reaction to common or suspected allergens (see Ch. 2, p. II. B.4.c.3).

in. The determination of the level of specific IgE is carried out using RAST (see Ch. 20, p. VII.B) and other methods based on the use of labeled antibodies to IgE. In approximately 80% of cases, the results of RAST coincide with the results of puncture tests. Determining the level of specific IgE has the following advantages: 1) this study is safe for the patient, 2) its results do not depend on skin reactivity and stability of allergen preparations. The disadvantages of this study include: 1) a small set of allergens used to detect antibodies, 2) lower sensitivity than intradermal samples, 3) time consuming, 4) high cost. The determination of the level of specific IgE is shown in 1) severe diffuse neurodermatitis, 2) reduced or increased skin reactivity, 3) history of anaphylactic shock, 4) taking H1-blockers.

Food provocative tests are usually not carried out, as they rarely cause allergic rhinitis. If there is a history of food allergy in the history, puncture tests with food allergens and determination of the level of specific IgE are indicated. However, the final conclusion about the role of food allergens in the development of rhinitis can be made only if its symptoms disappear after excluding foods containing one or another allergen from the diet and reappear when they are reused (see Chap. 14, p. Iv).

D. Provocative tests. The allergen preparation is applied to the nasal mucosa and monitor the appearance of characteristic signs of allergic rhinitis. Provocative tests are performed in cases where the results of skin tests are not consistent with the history.

1) When staging provocative samples, the following rules must be observed.

a) In order to avoid systemic allergic reactions, the study is carried out in an asymptomatic period.

b) 48 hours before the study, H1-blockers are canceled. Hydroxyzine, terfenadine and astemizole are canceled even earlier (see Ch. 4, p. VI).

c) In one nostril, an allergen solution is introduced in a dilution of 1: 1000 in the form of an aerosol or an allergen in the form of a powder.

d) A solvent is introduced into the other nostril (control).

2) With a positive result of a provocative test, itching in the nose appears, sneezing is separated from the nose, the mucous membrane becomes pale and swollen. For a quantitative assessment of the reaction, more complex techniques are used (for example, rhinomanometry), which, due to complexity and high cost, are used only for scientific purposes.

3) The disadvantages of provocative samples.

a) Conducting provocative tests takes time. At the same time, sensitization to only one allergen can be detected.

b) Samples are not informative during an exacerbation of allergic rhinitis.

c) During the test, a systemic allergic reaction may develop.

G. Treatment

1. Elimination of contact with the allergen. Eliminate contact with the allergen, avoid the action of adverse environmental factors (see chap. 4, paragraphs I – III).

a. For allergies to pollen, it is recommended to use air conditioners - in the summer they can reliably isolate housing from allergens. In winter, swelling of the nasal mucosa can cause dry air. To maintain optimal air humidity (about 40%), use room or central humidifiers. Electronic filters (room or central) remove more than 90% of the particles suspended in the air, but they are not effective enough to remove mites. In the United States, air conditioning, humidifiers, and electronic filters are tax deductible.

b. If contact with an allergen is unavoidable, the patient should wear a mask. Well-selected masks prevent inhalation of house dust, spores of fungi, particles of the epidermis of animals, aerosols and fibers contained in the air.

2. Drug treatment

a. H1-blockers are the basis of drug treatment for allergic rhinitis. Doses of these drugs are shown in table. 4.3.

1) H1-blockers should be taken if possible before contact with the allergen. During an exacerbation, drugs must be taken continuously.

2) The disadvantages of treatment with H1-blockers.

a) In many patients with atopic diseases, these drugs are ineffective. Perhaps this is due to their low concentration in tissues, which does not provide blockade of all H1 receptors. In addition, swelling of the mucosa causes not only histamine, but also other inflammatory mediators. Chronic inflammation of the nasal mucosa also contributes to a decrease in the effectiveness of H1 blockers.

b) Side effects. The most common side effect of first-generation H1 blockers is drowsiness. Excitement, irritability, insomnia, dizziness, tinnitus, impaired coordination, blurred vision, dysphagia, dry mouth, urinary retention, palpitations, and headache are less common. Loss of appetite, nausea, vomiting, diarrhea, or constipation are also possible. To prevent gastrointestinal disorders, drugs should be taken with meals. After several days of continuous use of H1-blockers, drowsiness and other side effects usually become less pronounced. H1-blockers that do not cross the blood-brain barrier, such as terfenadine, astemizole and loratadine, have almost no hypnotic effect. Terfenadine and astemizole can cause pirouette tachycardia. This side effect develops 1) when taking high doses of these drugs, 2) while prescribing drugs that reduce the rate of elimination of terfenadine and astemizole, such as erythromycin, ketoconazole, itraconazole, 3) with liver failure. In loratadine, this side effect is absent, however, when using this drug in patients with liver failure, it is recommended to increase the intervals between doses.

3) With prolonged treatment, the effectiveness of H1 blockers may decrease. In such cases, H1 blockers of another group are prescribed. In addition, the effectiveness of H1-blockers is significantly reduced with severe allergic rhinitis, secondary infection and nasal polyps.

4) The effectiveness of H1-blockers and the severity of side effects in different patients are not the same. With serious side effects, the dose of the drug is reduced.

5) H1-blockers can be prescribed for allergic rhinitis in patients with bronchial asthma. However, during an attack of bronchial asthma, these drugs should not be used, since they increase the viscosity of the mucus.

b. Alpha-adrenostimulants cause narrowing of the vessels of the nasal mucosa. In allergic rhinitis, alpha-adrenostimulants are used both for topical use and for oral administration (see table. 4.4).

1) Alpha-adrenostimulants for topical use (vasoconstrictor drugs for topical use) are quite effective and cause fewer side effects than with systemic use. Use these funds can only be for several days. Longer use leads to increased swelling of the mucosa. Preparations in the form of drops are instilled into the nose in the supine position with the head slightly tilted and turned to the side. After instillation, the patient should lie for 30-60 s. When using drugs in the form of an aerosol, the head is kept straight, slightly tilted forward.

2) Alpha-adrenostimulants for oral administration are used alone or in combination with H1-blockers.

in. Cromoline stabilizes the mast cell membrane, inhibits their degranulation, reduces the activity of eosinophils, neutrophils and monocytes. For allergic rhinitis, a 4% cromolyn solution is used in the form of a metered-dose aerosol (5.2 mg per inhalation). The drug is prescribed periodically - before possible contact with the allergen in seasonal allergic rhinitis - or constantly - with year-round allergic rhinitis. For some patients, cromolyn is prescribed in combination with H1-blockers and alpha-adrenostimulants.

1) Dose for adults and children over 6 years of age - 1 inhalation in each nostril 3-4 times a day. If necessary, the number of inhalations is increased to 6 per day. The patient is warned that before inhalation he should blow his nose and that the aerosol should be inhaled through the nose. The action of cromolyn often develops only 2-4 weeks after the start of treatment.

2) Side effects are minor and rarely observed. Most often, this is sneezing and a burning sensation in the nose. They are noted in less than 10% of patients. Rash and nosebleeds occur in less than 1% of patients. Cromoline does not have sleeping pills.

Mr. Nedocromil, like cromolin, but more effectively inhibits the release of inflammatory mediators. With topical application of an aqueous solution of nedocromil, there are no side effects. In the United States, Nedocromil has so far been approved for use only in bronchial asthma.

e. Corticosteroids for topical use are indicated for severe seasonal allergic rhinitis in cases where other drugs are ineffective. Beclomethasone, flunisolid, budesonide, triamcinolone or mometasone are prescribed. These topical preparations are not absorbed and are rapidly destroyed. In allergic rhinitis, they are as effective as previous generation corticosteroids, such as dexamethasone, but they cause fewer side effects. Beclomethasone is available in the form of an aerosol and an aqueous solution, mometasone - in the form of a metered aerosol. The patient should be warned that corticosteroids, unlike H1-blockers and vasoconstrictors, cause improvement only after a few days of use. During periods of increased concentration of allergens in the air, corticosteroids, like cromolyn, are prescribed continuously.

1) Doses. Beclomethasone for adults and children over 12 years of age is prescribed 1 inhalation (42 μg) in each nostril 2-4 times a day, for children 6-12 years old - 1 inhalation in each nostril 3 times a day. The use of corticosteroids for allergic rhinitis in children under 6 years of age has not been studied. The recommended initial dose of flunisolid for adults is 2 inhalations (50 mcg) in each nostril 2 times a day, for children 6-14 years old - 1 inhalation in each nostril 3 times. The initial dose of triamcinolone and mometasone (for adults and children over 12 years old) - 2 inhalations in each nostril once a day, budesonide (for adults and children over 6 years old) - 2 inhalations in each nostril in the morning and evening or 4 inhalations in each nostril in the morning (256 mcg / day). With the ineffectiveness of the drugs in the recommended doses, as well as with a seasonal increase in the concentration of allergens, the dose of corticosteroids is increased. At the end of the exacerbation, the dose is again reduced. The patient is explained how to use the inhaler correctly. The aerosol jet cannot be directed towards the nasal septum. To avoid accidental ingestion of the drug in the eyes, the tip of the inhaler should be inserted into the nostril.

2) Side effects. Sneezing and a burning sensation in the nose are usually observed. 5% of patients have nosebleeds. In rare cases, rhinitis and pharyngitis caused by Candida albicans and ulceration of the nasal mucosa develop. Systemic reactions with the use of drugs in recommended doses are not observed.

3) With severe swelling of the mucosa during the first 2-3 days of treatment 1-15 minutes prior to inhalation of corticosteroids, vasoconstrictors are prescribed for topical use. Particular caution should be observed when prescribing corticosteroids for topical administration to patients with tuberculosis or undergoing it, as well as to patients with herpetic eye damage.

4) Не рекомендуется производить инъекции кортикостероидов длительного действия в слизистую носовых раковин, поскольку описаны случаи эмболии артерий сетчатки с последующим развитием слепоты.

е. При тяжелом обострении аллергического ринита, когда другие методы лечения неэффективны, назначают кортикостероиды для системного применения. Курс лечения не должен превышать 7 сут, поскольку более длительное системное применение кортикостероидов сопровождается серьезными осложнениями.

ж. Ипратропия бромид при местном применении уменьшает количество отделяемого из носа. Отек слизистой и чихание этот препарат не устраняет. В США препараты ипратропия бромида для местного применения не выпускаются.

3. Десенсибилизация показана при сенсибилизации к тем воздушным аллергенам, контакт с которыми неизбежен — пыльце растений, грибам, микроклещам (см. гл. 4, пп. XIV—XXIII). Потребность в десенсибилизации определяется частотой, тяжестью и продолжительностью обострений сезонного аллергического ринита, а также эффективностью других методов лечения.

Д. Прогноз. Сезонный аллергический ринит характеризуется длительным, рецидивирующим течением. Его тяжесть зависит от состояния окружающей среды и реактивности организма. На протяжении жизни картина заболевания может меняться. Все симптомы обычно становятся менее выраженными в период полового созревания, а к 20—40 годам вновь усиливаются. Во время беременности часто наблюдается ремиссия аллергического ринита, а в постменопаузе, напротив, — обострение. У детей сезонный аллергический ринит не повышает риск экзогенной бронхиальной астмы, хотя экзогенная бронхиальная астма в этом возрасте повышает риск сезонного аллергического ринита.
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Сезонный аллергический ринит

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    Acute allergic diseases are caused by increased sensitivity of the immune system to various exogenous antigens (allergens). They are characterized by a sudden onset, an unpredictable course, a high risk of developing life-threatening conditions. ETIOLOGY AND PATHOGENESIS The most common allergens: евые food (fish, seafood, nuts, honey, milk, eggs, fruits, legumes, etc.); ¦
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    Для круглогодичного аллергического ринита характерны частые обострения, не зависящие от времени года, или постоянное течение. Несмотря на сходство клинических проявлений с сезонным аллергическим ринитом, круглогодичный аллергический ринит рассматривают как самостоятельную форму ринита. A. Pathogenesis. Изменения слизистой носа при круглогодичном аллергическом рините выражены меньше, но имеют
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  5. Другие аллергические риниты. У-30.1
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    {foto22} Исход лечения: Клинические критерии улучшения состояния больного: 1. Нормализация температуры. 2. Normalization of laboratory parameters. 3. Улучшение клинических симптомов заболевания (затруднение дыхания, выделения из
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    Острые и хронические аллергические заболевания околоносовых пазух представляют собой особую категорию патологических состояний слизистой оболочки верхних дыхательныхпутей, возникающих в результате повышенной чувствительности организма больного к чужеродному белку (антигену илиаллергену) и вследствие неврогенных и эндокринных расстройств. В патологии заболевания большая роль принадлежит
  8. Сезонный синдром
    Физическая блокировка Человек, страдающий сезонным синдромом, испытывает усталость, сонливость и подавленность в те времена года или дня, для которых характерно снижение естественной освещенности. Эмоциональная блокировка Интересно отметить, что все симптомы этого недуга исчезают после нескольких солнечных дней и человек вновь чувствует себя отлично. Факт зависимости от внешней освещенности
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  10. Вазомоторный ринит
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  11. Эозинофильный неаллергический ринит
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  12. Хронические риниты
    Единой классификации хронических ринитов до настоящего времени нет. Многочисленные попытки создать приемлемую классификацию хронических ринитов, учитывающую особенности этиологии, патогенеза, морфологических и типических вариантов, еще не получили полного завершения и продолжаются до настоящего времени. Между тем, классификация Л.Б.Дайняк (1987), учитывающая ряд позиций других классификаций,
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