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Allergic Rhinitis | Rhinitis | Nose | Otorhinolaryngology (Ear Nose Throat / E.N.T) | 4th Year (Fourth Year) | MBBS | Detailed Free Notes

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1. DEFINITION

  • Allergic rhinitis is a chronic inflammatory disorder of the nasal mucosa

  • Caused by IgE-mediated type I hypersensitivity reaction

  • Occurs after exposure to environmental allergens

  • Characterized by:

    • Sneezing

    • Nasal itching

    • Rhinorrhea

    • Nasal obstruction

2. IMPORTANCE IN ENT PRACTICE

  • One of the most common ENT conditions

  • Major cause of:

    • Chronic nasal obstruction

    • Sleep disturbance

    • Poor academic performance

    • Reduced quality of life

  • Strong association with:

    • Asthma

    • Sinusitis

    • Otitis media with effusion

  • Frequently asked in:

    • Viva

    • MCQs

    • OSCE

    • Long questions

3. EPIDEMIOLOGY

  • Affects all age groups

  • More common in:

    • Children

    • Young adults

  • Urban prevalence > rural

  • Increasing incidence due to:

    • Air pollution

    • Industrialization

    • Lifestyle changes

4. ETIOLOGY

4.1 ALLERGENS (VERY HIGH-YIELD)

A. INHALANT ALLERGENS

  • House dust mites

  • Pollens (grass, trees, weeds)

  • Animal dander

  • Molds

  • Cockroach allergens

B. SEASONAL ALLERGENS

  • Pollens (spring, autumn)

C. PERENNIAL ALLERGENS

  • Dust mites

  • Animal dander

  • Fungi

5. RISK FACTORS

  • Genetic predisposition (atopy)

  • Family history of:

    • Asthma

    • Eczema

    • Allergic rhinitis

  • Environmental pollution

  • Passive smoking

  • Early childhood infections

  • Indoor allergens

6. CLASSIFICATION (EXAM FAVORITE)

6.1 BASED ON DURATION (ARIA CLASSIFICATION)

A. INTERMITTENT

  • Symptoms < 4 days/week

  • Or < 4 weeks/year

B. PERSISTENT

  • Symptoms ≥ 4 days/week

  • And ≥ 4 weeks/year

6.2 BASED ON SEVERITY

A. MILD

  • Normal sleep

  • No impairment of daily activities

  • No troublesome symptoms

B. MODERATE-SEVERE

  • Sleep disturbance

  • Impaired daily activities

  • Poor school/work performance

  • Troublesome symptoms

7. PATHOGENESIS (CORE CONCEPT)

7.1 IMMUNOLOGICAL BASIS

  • Type I hypersensitivity reaction

  • Mediated by:

    • IgE

    • Mast cells

    • Eosinophils

7.2 SENSITIZATION PHASE

  • First exposure to allergen

  • Allergen taken up by antigen-presenting cells

  • Presented to Th2 lymphocytes

  • Release of cytokines:

    • IL-4

    • IL-5

    • IL-13

  • B-cells produce allergen-specific IgE

  • IgE binds to mast cells

7.3 RE-EXPOSURE PHASE

  • Allergen binds IgE on mast cells

  • Mast cell degranulation occurs

  • Release of mediators:

    • Histamine

    • Leukotrienes

    • Prostaglandins

7.4 PHASES OF ALLERGIC RESPONSE

A. EARLY PHASE (Minutes)

  • Histamine release

  • Sneezing

  • Itching

  • Watery rhinorrhea

B. LATE PHASE (Hours)

  • Cellular infiltration:

    • Eosinophils

    • Basophils

  • Nasal congestion

  • Persistent inflammation

8. PATHOLOGICAL CHANGES

8.1 GROSS

  • Pale, bluish nasal mucosa

  • Edematous turbinates

  • Watery secretions

8.2 MICROSCOPY

  • Eosinophilic infiltration

  • Edema of lamina propria

  • Increased goblet cells

  • Dilated blood vessels

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

9. CLINICAL FEATURES

9.1 NASAL SYMPTOMS

  • Paroxysmal sneezing (multiple sneezes)

  • Nasal itching

  • Profuse watery rhinorrhea

  • Nasal obstruction (bilateral)

9.2 OCULAR SYMPTOMS

  • Itching of eyes

  • Watering

  • Redness

  • Allergic conjunctivitis

9.3 SYSTEMIC / ASSOCIATED FEATURES

  • Itching of palate

  • Throat clearing

  • Cough

  • Fatigue

  • Sleep disturbance

10. PHYSICAL SIGNS (VERY IMPORTANT)

10.1 NASAL EXAMINATION

  • Pale, boggy nasal mucosa

  • Inferior turbinate hypertrophy

  • Clear watery discharge

10.2 CHARACTERISTIC SIGNS

  • Allergic salute

    • Repeated upward rubbing of nose

  • Allergic crease

    • Horizontal line across nasal bridge

  • Dennie-Morgan folds

    • Infraorbital skin folds

11. DIFFERENTIAL DIAGNOSIS

  • Vasomotor rhinitis

  • Acute viral rhinitis

  • Chronic sinusitis

  • DNS

  • Nasal polyps

12. COMPLICATIONS

  • Chronic sinusitis

  • Otitis media with effusion

  • Nasal polyposis

  • Sleep apnea

  • Bronchial asthma

13. INVESTIGATIONS (EXAM-ORIENTED, PRACTICAL FOCUS)

13.1 BASIC INVESTIGATIONS

  • Complete Blood Count (CBC)

    • Eosinophilia common

    • Supports allergic etiology

  • Absolute Eosinophil Count (AEC)

    • Raised in allergic individuals

    • Not specific but supportive

13.2 NASAL SMEAR FOR EOSINOPHILS

  • Simple, low-cost test

  • Presence of eosinophils favors allergic rhinitis

  • Helps differentiate from infective rhinitis

13.3 SERUM IgE LEVELS

  • Elevated total IgE

  • Indicates atopy

  • Not diagnostic alone

13.4 SKIN PRICK TEST (GOLD STANDARD FOR ALLERGEN IDENTIFICATION)

  • Detects specific allergen sensitivity

  • Performed on forearm or back

  • Wheal and flare reaction within 15–20 minutes

Indications

  • Persistent symptoms

  • Planning immunotherapy

  • Poor response to treatment

13.5 RADIOLOGY

  • Not routine

  • X-ray PNS / CT PNS only if:

    • Sinusitis suspected

    • Complications present

14. DIAGNOSIS

  • Primarily clinical

  • Based on:

    • Typical symptoms

    • Pale boggy mucosa

    • Positive allergy history

  • Investigations used to:

    • Confirm allergy

    • Identify allergen

    • Rule out complications

15. MANAGEMENT — STEPWISE (ARIA GUIDELINES, VERY HIGH-YIELD)

15.1 GENERAL PRINCIPLES

  • Avoidance of allergens

  • Step-up and step-down approach

  • Long-term control rather than cure

  • Combination therapy often required

16. ALLERGEN AVOIDANCE (FOUNDATION OF MANAGEMENT)

16.1 HOUSE DUST MITE CONTROL

  • Frequent washing of bedding

  • Use of mite-proof covers

  • Avoid carpets and heavy curtains

  • Maintain low humidity

16.2 POLLEN AVOIDANCE

  • Keep windows closed during high pollen season

  • Avoid outdoor activities early morning

  • Use face masks if required

16.3 ANIMAL DANDER

  • Avoid pets

  • Restrict animals from bedroom

17. PHARMACOLOGICAL MANAGEMENT (CORE ENT CONTENT)

17.1 ANTIHISTAMINES

A. FIRST-GENERATION (SEDATING)

  • Chlorpheniramine

  • Diphenhydramine

Disadvantages

  • Sedation

  • Anticholinergic effects

  • Not preferred

B. SECOND-GENERATION (NON-SEDATING) — PREFERRED

  • Loratadine

  • Cetirizine

  • Fexofenadine

  • Desloratadine

Advantages

  • Effective against sneezing, itching, rhinorrhea

  • Minimal sedation

17.2 INTRANASAL CORTICOSTEROIDS (DRUG OF CHOICE)

  • Most effective treatment for allergic rhinitis

  • Act on:

    • Nasal obstruction

    • Sneezing

    • Rhinorrhea

    • Inflammation

Common Drugs

  • Fluticasone

  • Mometasone

  • Budesonide

Mechanism

  • Reduce inflammatory mediators

  • Decrease eosinophils

  • Reduce mucosal edema

Correct Technique (VIVA FAVORITE)

  • Spray directed away from septum

  • Prevents septal perforation

17.3 DECONGESTANTS

A. TOPICAL

  • Xylometazoline

  • Oxymetazoline

Important

  • Use for maximum 5–7 days

  • Prolonged use → Rhinitis medicamentosa

B. ORAL

  • Pseudoephedrine

Caution

  • Hypertension

  • Cardiac disease

17.4 LEUKOTRIENE RECEPTOR ANTAGONISTS

  • Montelukast

Indications

  • Allergic rhinitis with asthma

  • Add-on therapy

17.5 MAST CELL STABILIZERS

  • Sodium cromoglycate

Role

  • Preventive

  • Less effective

  • Safe in children and pregnancy

17.6 ANTICHOLINERGIC SPRAYS

  • Ipratropium bromide

Use

  • Severe watery rhinorrhea

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

18. IMMUNOTHERAPY (DESENSITIZATION)

18.1 DEFINITION

  • Gradual administration of increasing doses of allergen

  • Modifies immune response

18.2 INDICATIONS

  • Moderate to severe allergic rhinitis

  • Identified allergen

  • Poor response to medication

  • Patient compliance

18.3 TYPES

  • Subcutaneous immunotherapy (SCIT)

  • Sublingual immunotherapy (SLIT)

18.4 ADVANTAGES

  • Long-term benefit

  • Reduces progression to asthma

  • Disease-modifying

18.5 DISADVANTAGES

  • Time-consuming

  • Risk of anaphylaxis (rare)

  • Requires specialist supervision

19. SURGICAL MANAGEMENT (LIMITED ROLE)

19.1 INDICATIONS

  • Inferior turbinate hypertrophy

  • Nasal obstruction refractory to medical therapy

  • Associated DNS or polyps

19.2 PROCEDURES

  • Turbinoplasty

  • Submucosal diathermy

  • Partial turbinectomy

  • Septoplasty (if DNS present)

20. COMPLICATIONS OF ALLERGIC RHINITIS

  • Chronic sinusitis

  • Otitis media with effusion

  • Nasal polyps

  • Sleep apnea

  • Bronchial asthma

21. DIFFERENTIATION FROM OTHER RHINITIS (EXAM TABLE)

Feature Allergic Vasomotor Infective
Sneezing ++ + –
Itching ++ – –
Discharge Watery Watery Purulent
Eosinophils Present Absent Absent
Seasonality Common No No

22. HIGH-YIELD VIVA QUESTIONS

  • Drug of choice in allergic rhinitis?

  • Why intranasal steroids preferred?

  • Difference between allergic and vasomotor rhinitis?

  • Complications of untreated allergic rhinitis?

  • What is allergic salute?

23. CLINICAL SCENARIO (EXAM STYLE)

A 16-year-old boy presents with recurrent sneezing, watery nasal discharge, and itching worse in spring.

Diagnosis

  • Seasonal allergic rhinitis

Management

  • Allergen avoidance

  • Intranasal corticosteroids

  • Second-generation antihistamines

24. SPECIAL SITUATIONS (EXAM-RELEVANT, CLINICAL FOCUS)

24.1 ALLERGIC RHINITIS IN CHILDREN

  • Common presentation:

    • Recurrent sneezing

    • Mouth breathing

    • Snoring

    • Poor school performance

  • Associations:

    • Adenoid hypertrophy

    • Otitis media with effusion

    • Asthma (atopic march)

Management Principles

  • Allergen avoidance emphasized

  • Second-generation antihistamines preferred

  • Intranasal corticosteroids safe when used correctly

  • Avoid prolonged topical decongestants

  • Consider immunotherapy in persistent disease

24.2 ALLERGIC RHINITIS IN PREGNANCY

  • Physiological nasal congestion common

  • Drug safety is key

Safe Options

  • Saline sprays

  • Intranasal corticosteroids (budesonide preferred)

  • Loratadine / cetirizine (if required)

Avoid

  • Oral decongestants

  • Prolonged topical decongestants

24.3 ALLERGIC RHINITIS WITH ASTHMA

  • Upper and lower airway share inflammatory pathway

  • Poor rhinitis control worsens asthma

Management

  • Treat rhinitis aggressively

  • Intranasal steroids reduce asthma exacerbations

  • Montelukast useful add-on

25. RHINITIS MEDICAMENTOSA (VERY HIGH-YIELD)

25.1 DEFINITION

  • Rebound nasal congestion due to prolonged use of topical nasal decongestants

25.2 PATHOGENESIS

  • Chronic vasoconstriction

  • Ischemia of nasal mucosa

  • Loss of vasomotor tone

  • Rebound vasodilation

  • Persistent nasal obstruction

25.3 CLINICAL FEATURES

  • Severe nasal blockage

  • Temporary relief after spray use

  • Dryness and crusting

  • Anxiety related to nasal blockage

25.4 MANAGEMENT

  • Gradual withdrawal of decongestant

  • Intranasal corticosteroids

  • Saline irrigation

  • Patient counseling (critical)

26. DIFFERENT TYPES OF RHINITIS — QUICK DIFFERENTIATION

Feature Allergic Vasomotor Atrophic
Itching Present Absent Absent
Sneezing Frequent Occasional Absent
Discharge Watery Watery Foul-smelling
Mucosa Pale, boggy Congested Atrophic
Eosinophils Present Absent Absent

27. SURGICAL OPTIONS — WHEN MEDICAL THERAPY FAILS

27.1 INDICATIONS

  • Persistent nasal obstruction

  • Inferior turbinate hypertrophy

  • Associated DNS or polyps

  • Poor response to optimal medical therapy

27.2 PROCEDURES

  • Inferior turbinoplasty

  • Submucosal diathermy

  • Radiofrequency turbinate reduction

  • Septoplasty (if DNS present)

Note

  • Surgery does not cure allergy

  • Improves airflow and drug delivery

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

28. PREVENTION STRATEGIES (SEO-FRIENDLY, PRACTICAL)

  • Early identification of allergens

  • Environmental control

  • Avoid passive smoking

  • Correct nasal spray technique

  • Early treatment to prevent complications

  • Patient education and compliance

29. OSCE / PRACTICAL EXAM CHECKLIST

29.1 HISTORY STATION

  • Sneezing pattern

  • Seasonality

  • Family history of atopy

  • Trigger exposure

  • Impact on sleep/work

29.2 EXAMINATION STATION

  • Pale boggy mucosa

  • Inferior turbinate hypertrophy

  • Watery discharge

  • Associated DNS or polyps

29.3 MANAGEMENT STATION

  • Diagnosis: Allergic rhinitis

  • Stepwise treatment (ARIA)

  • Drug of choice: Intranasal corticosteroids

  • Allergen avoidance advice

30. HIGH-YIELD VIVA QUESTIONS (FINAL SET)

  • Define allergic rhinitis.

  • Type of hypersensitivity involved?

  • Drug of choice?

  • ARIA classification?

  • Difference between allergic and vasomotor rhinitis?

  • Complications of untreated allergic rhinitis?

  • Indications for immunotherapy?

  • What is allergic salute?

31. MCQs (EXAM-ORIENTED)

1. Drug of choice for allergic rhinitis:
A. Antihistamines
B. Decongestants
C. Intranasal corticosteroids
D. Antibiotics
Correct Answer: C

2. Pathophysiology involves:
A. Type II hypersensitivity
B. Type III hypersensitivity
C. Type I hypersensitivity
D. Type IV hypersensitivity
Correct Answer: C

3. Most common complication:
A. Epistaxis
B. Sinusitis
C. Septal perforation
D. DNS
Correct Answer: B

32. FINAL CLINICAL PEARLS

  • Allergic rhinitis is chronic but controllable

  • Intranasal corticosteroids are most effective

  • Treat upper airway to control lower airway disease

  • Avoid long-term decongestant use

  • Immunotherapy is disease-modifying

  • Early control prevents sinusitis, asthma, and polyps

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

Hunain Zia

Hunain Zia has previously achieved considerable success in the high-school educational stream, gaining a massive 154 Total A Grades and 7 Major Distinctions, a process in which he broke/ set 11 different world records, including the most A grades ever achieved, most subjects ever appeared in, most distinctions, gaining distinctions across two separate boards (Pearson Edexcel and CAIE) within the same year/ ever, and even 19 hours of constant examination. All records stand intact today. Hunain pursued his Honors Accounting Degree from the prestigious Bentley University, and then completed an LLB (in Honors) from University of London. Currently, he manages multiple social and commercial projects, has founded digital streams and works tirelessly in the education sector.

Educate A Change focuses on truly bringing change in the educational sector worldwide. All our courses are designed to ensure success, and provide complete preparation without requiring any other external material. Therefore, it takes away the expense of academies, books, past paper compilations and other miscellaneous items. Instead, by just the courses we offer, the student can prepare fully for the best grades in their CAIEs, Edexcel and other high-school exams. The earnings from our course-sales are invested in social projects and growing the free educational activities of Educate A Change.