( ..

- ()
, () ()

( ..)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

-
.
..
..
..
..
...
..
..
..
..
..
..
..
..
..
..
..
..
....
..
..
..
..
..
..
..
..
..

.
.





.
.
.


..
..

.
.

..
.
..
..

.
..

.

 ( ..)

2543
()
,



()
2553 () 28

2544

()

...................................................
....................................................
( )
( )

....................................................
( )
()

(Contents)

-
Introduction and Methodology

-
Definitions and Classification

-
Comorbidities and Complications

-
Principle of Management

-
Avoidance and Prevention

-
Pharmacotherapy

- ()
Allergen immunotherapy

-
Surgical treatment

-
Complementary Alternative Medicine and Referral

-
Special considerations

-

-
Appendix


1

2

3

4

5

6



7

5
9
16
20
20
22
28
30
32
33
70
72

(Classification of rhinitis)



(teratogenicity-risk classification)
(US-FDA)

74
76
14
24
77
35
36

 ( ..)

( .. )

(International Study of Asthma and

Allergies in Childhood, ISAAC questionnaires) .. 2538 .. 2544
6-7 32.6 43.2 13-14
43.4 57.4(1)
ISAAC 3,631 12
61.9 26.3
(2) ..2538
1,147 21.9(3)

25(4-5) ISAAC
(6)


-(7)
(Short- form 36, SF-36 questionnaire) (Rhinoconjunctivitis , Rcq-36
questionnaire )(8-9)


,
, , , ,
(World Allergy
Organization, WAO) .. 2548 ,
20,000
The Index of Medical Specialties .. 2547
1,087

() (
)

.. 2544(10)
.. 2544

()

(option)

 ( ..)

( .. )

.. 2544 (.. ) (.
. ) () ..
.. 2544

1. ()



2. () ..
.. ..
( )

3.

4. , ,
, , , ,


5.

1.

2.

3.

4.
(systematic error bias)
(random error)

5.
6.
7.
8.

1. Medline PubMed (www.pubmed.com) (practice guideline[pt] OR
guideline*[ti]) AND rhinitis[ti] ..2545 31 2554 35
6 (11-18) National Guideline Clearinghouse (http://www.guideline.gov)
allergic rhinitis
or nasal allergy 57 4 (18)

2. Evidence in Health and Social Care (http://www.evidence.nhs.uk)
allergic rhinitis

3. Sign Scottish Intercollegiate Guidelines Network (http://www.
sign.ac.uk/) , CMA Infobase: Clinical Practice
Guidelines (CPGs) (http://www.cma.ca/clinicalresources/practiceguidelines)
Guidelines Group (http://www.nzgg.org.nz)
allergic rhinitis

1. (10)

2. -2541(19)

3. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health

Organization, GA(2)LEN and AllerGen)(14)

4. Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines: 2010 revision.(18)

5. BSACI guidelines for the management of allergic and non-allergic rhinitis.(15)

6. The diagnosis and management of rhinitis: an updated practice parameter(16)

7. International Primary Care Respiratory Group (IPCRG) Guidelines: management of allergic rhinitis.(11)

8. Allergy diagnostic testing: an updated practice parameter(20)

 ( ..)

9. Allergen immunotherapy: a practice parameter second update. (21)

10. Immunotherapy (22)

(23)
1

( ..)

IgE

(seasonal allergic rhinitis) (perennial allergic rhinitis)

(WHO-ARIA)(14)



1. Intermittent () 4

4

2. Persistent () 4

4

2

1. (mild)

10

2. (moderate to severe)

1.




1 (14)



-

(24)

- , , ,

-

-




2.

-

(long face syndrome)

(allergic shiner) (allergic nasal crease/line)

allergic salute,

(mouth breathing)

 ( ..)

11

-




(lymphoid hyperplasia)

(nasal endoscopy)


- (retraction)


(cobble stone / granular pharynx)

(nasal endoscopy)

[strong recommendation, low quality
of evidence]

3.

3.1
IgE (in vivo tests) (in vitro tests)

3.1.1 (allergy skin test)
IgE (immediate hypersensitivity)
, , ,

(resuscitation) (severe
anaphylaxis)

(scratch tests), (intradermal/intracutaneous tests)
(prick tests)

12
(negative control) phenol buffered saline dermatographism
(positive control) histamine
dihydrochloride/phosphate 15 (wheal)
3 (25)


-


-

-
(26)

-
(27) 2 ()

systemic
reaction

3.1.2 (in vitro tests) serum-total IgE, serumspecific IgE, peripheral
blood activation markers nasal secretion-specific IgE


3.1.3

- Nasal provocation (challenge) tests


(28)







(bronchial asthma)
bronchial provocation test.

(occupational agents)
,

 ( ..)

13

, in vitro tests nasal provocation tests the composite
gold standard(27)

- Nasal cytology and histology
2
nasal cytology non-allergic
rhinitis with eosinophilia syndrome (NARES), infectious rhinitis

- Nasal endoscopy middle meatus


-


- Mucociliary function test

(immotile cilia syndrome)

- Nasal airway assessment rhinomanometry, acoustic rhinometry
peak nasal inspiratory flow (29-32)


- Olfactory tests (odour discrimination) (odour identification)
(odour threshold)

1.

(allergen immunotherapy,
)



2. serum-specific IgE


3.


[strong recommendation, low quality of
evidence]

14

WHO-ARIA .. 2544(33)
3
3 (Classification of rhinitis)

Infectious

Viral

Bacterial

Other infectious agents

Allergic


Intermittent

Persistent

Occupational (allergic and non-allergic)

Intermittent

Persistent

Drug-induced

Aspirin

Other medications

Hormonal

Others

NARES

Irritants

Food-induced (gustatory)

Emotional

Atrophic rhinitis

Gastroesophageal reflux

Idiopathic

(31) 4

 ( ..)

15

4 :

Rhinosinusitis with or without nasal polyps

Mechanical factors

Deviated nasal septum

Hypertrophic turbinate

Adenoid hypertrophy

Anatomical variants in the ostiomeatal complex

Foreign bodies

Choanal atresia

Tumours

Benign

Malignant

Granulomas

Wegeners granulomatosis

Sarcoidosis

Infectious

Malignant-midline destructive granuloma

Ciliary defects

Cerebrospinal rhinorrhea

allergic march
(atopic dermatitis) 6
2 40 (24, 34)
, ,
, (allergic conjunctivitis) (otitis media with effusion)


serum -specific IgE
(14, 26)

16
(co-morbidities)
(Bronchial asthma)



(nose-lung interaction)(35)
(36) (one airway, one disease)

(33)
26-59.7(37)
(persistent allergic rhinitis)
(intermittent allergic rhinitis) (38)
(39)

2-3 (40)

Adenoid hypertrophy

CD1a, Langerhans cell eosinophil

(41) IL4, IL5 IgE positive cell
adenoid hypertrophy


(intranasal corticosteroid)
(42)



, antileukotrienes(33, 36)
, , ,

 ( ..)

17

Chronic cough

8
(postinfectious cough), , , , ,
, , , , (43)

(postnasal drip)
(44)

(45)

(46)
(ocular allergy)

, /
,

1. Allergic conjunctivitis: type I hypersensitivity
,
(hyperemia), (chemosis)
75 allergic conjunctivitis (47-50)
2

Seasonal allergic conjunctivitis: seasonal allergic rhinitis(51)
(52)

Perennial allergic conjunctivitis: perennial allergic rhinitis
, ,
(53-54)


2. Vernal keratoconjunctivitis: 60
11-20 (55) allergic conjunctivitis
(photophobia) (seasonal
exacerbation) giant papillae upper tarsal conjunctiva(56-59)
Type II type I hypersensitivity(59) 20
(60)

18

3. Atopic keratoconjunctivitis: mast cell /
lymphocyte-mediated(47-48) 30-50
allergic conjunctivitis
95 87
(47, 61)
(Tubal dysfunctions, Otitis media with effusion/OME )

OME 7
80 3 1
40 3 (62)

- OME (63-64)
(65) OME (66-68)
OME OME
(69) OME (70-71)
OME(72)

- tympanometry
(73) nasal challenge
(74) OME
(75-76) OME eosinophils, IL4, IL5
(77) OME

- OME OME (78)
OME 85 (79)
Sleep-disordered breathing


(obstructive sleep-disordered breathing; OSDB) (80-82) (83-88)
(89-90) (89,91-92)
inflammatory mediators (93-94)
(81) (95-96)

(97) (98-99)

 ( ..)

19

(100) (101-102)
(Continuous Positive Airway Pressure, CPAP)
(103-105) (sleep test) (102, 106-108)
obstructive sleep apnea (OSA)
(109) (94)
(94)
OSA

OSDB(85,110-115) (116)
second generation(84, 94, 109, 117)
(94) montelukast
(118)
(radiofrequency inferior turbinate reduction)
(100-102)

vocal cord dysfunction (119)
(allergic inflammation) vocal cord edema
nasal provocation test
vocal cord edema
laryngeal edema(14)
(Gastroesophageal Reflux Disease/GERD)


(120)
laryngopharyngeal reflux(LPR)

(non-specific hyperreactivity)(121)

20

(patient education & general health measures)

/
(allergen avoidance and environmental control)

(pharmacotherapy)

(allergen immunotherapy)

/
(Allergen avoidance and environmental control)
high efficiency particulate air filters

(meta-analysis)
high efficiency particulate air filters (HEPA filters)
24 (122)

2-4 (123)
high efficiency particulate air filters

[weak recommendation, very low quality
of evidence]

55-60 oC
(124-125)

(124)

 ( ..)

21

[weak recommendation, high quality of
evidence]

Blatella germanica (Bla g 1)
sensitization threshold asthma threshold (126)




(Bla g 1)
(127)

[weak recommendation, moderate

quality of evidence]

(Atopy)


3
(128)

12
hydrolyse formula 6-12

22
12-18 , 24 , 36
(129)

6
hypoallergenic formula

sensitization rate
(130)

(131)
8

2-3 7 2.3 (132)

[weak recommendation, high quality of
evidence]

[strong recommendation, moderate
quality of evidence]

1. (Antihistamines)

1.1 (oral H1-antihistamines)
(H1-receptor) neutral antagonist inverse agonist(133)
(antiallergic anti-inflammatory effect) (134-135) 1 (
, , anticholinergic effect, fatigue irritability
) 2(136-142) 2
, , (intermittent allergic
rhinitis) ) (moderate to severe)

 ( ..)

23

,
, , (143)
(144-146)
6 (146-147)
6 2 , 2

1.2 (topical H1-antihistamine)
, , , (148-150)
5
, , , (151-152)
(153)
( 30 )

1.3 (H1- antihistamines + decongestants)
2

, ,
(154-159) 2 (
) (compliance)
fixed dose combination
decongestant

2

[strong recommendation, high quality
of evidence]

24

A, B Shekelle (160)
A = directly based on randomized controlled trials and meta-analyses
B = evidence from at least one controlled study without randomization or extrapolated recommendation from
category A evidence
2. (Nasal corticosteroids)

(162) (163-164)
(153, 165)
cromoglycate(166) antileukotrienes (167-168) antileukotrienes(169-172)
(14)
(173-174)
/ antileukotrienes
7-8 .
1-2 (175)
2 . (176) (177-179)
(180)
(181)
(171, 182-184) 1

 ( ..)

25

( 2 4) ( 12)(185)
(186)

first past hepatic inactivation
systemic bioavailability hypothalamic-pituitary-adrenal axis
systemic side effect (187-192) 1 perennial
allergic rhinitis 6-9 1 aqueous beclomethasone dipropionate 168 g BID
() (193) fluticasone
propionate, fluticasone furoate, mometasone furoate, budesonide (189, 194-195)
(196)
(197-198)
2-4
1
1 (14)
prednisolone 20-40 / 2 (199-200)

[strong recommendation, high quality
of evidence]

2


antileukotrienes

26

[strong recommendation, high quality
of evidence]




[weak recommendation, moderate quality of evidence]
Antileukotrienes

Cysteinyl leukotrienes (cysLTs) potent inflammatory mediator mast cells basophils
cysLTs arachidonic acid leukotriene C4, D4 E4
early late phase allergic reaction

montelukast leukotriene receptor antagonist cysLTs
receptors (14, 118, 185, 201-217)
montelukast 2
(203-205,207,209,216-217)

(205, 216)

pseudoephedrine(212-213)
montelukast

Cromones (Sodium cromoglycate, nedocromil)

(mediators) mast cells(15, 218)

(decongestants)

/(219-220)
10 / / 5
(rebound congestion) rhinitis medicamentosa(221-222)
(15)

30 rhinitis medicamentosa /
(15) systemic side effects

 ( ..)

27

monoamine oxidase inhibitors, hydrazine, flurazoridone, curcumin(),
2
Topical anticholinergic (ipratropium bromide)

(223-225)

(urinary retention) (glaucoma) (15)
Anti-IgE

Anti-IgE ..2530 anti-IgE receptor IgE mast cells,
basophils membrane bounded-IgE (mIgE) IgE-expression B cells(226) anti-IgE high
affinity FceRI IgE IgE 84-99(227) anti-IgE
405 12-74 anti-IgE
(228) 8
anti-IgE(229) anti-IgE Free IgE
(230-231)
(231)
anti-IgE 221 ( 6-17 ) RCT
anti-IgE 24 (232)
anti-IgE FceR1 IgE immune tolerance
maintenance dose (233)
anti-IgE

( 6 )


(234)

skin rash (urticaria) headache, URI, sinusitis, nasopharyngitis
(235)
anaphylaxis 1:1723 (235)

28
Anti-IgE

Anti-IgE

[weak recommendation, low quality of
evidence]

(Allergen immunotherapy)

Noon Freeman ..2454(236-237)

(238)
IgG4 IgE (239-242)
IgG4 IgG4(243-245)
T helper 1 (Th1)
Th2(239, 246-251) Th2
T regulatory (Treg) (252-254)
CD8+ (255) inflammatory cell recruitment activation inflammatory
cells (248, 256-263)


(264)
2
(264-269) 3 - 4
3-12 (265, 270) (sublingualswallow) (271-272)
(273-274)
(33, 275)

(238, 261, 276-285) (286-289) Alternaria (290) , Candida

Cladosporium nasal
immunotherapy (291-296) sublingual-swallowing immunotherapy
/ (297-312) (313-317)

 ( ..)

29

(318)

1. specific IgE

2.

3.

4. ,

5. /

1. severe asthma

2. significant immunodeficiency

3. malignancy

4. significant cardiovascular disease

5. beta-blocker

6.

7. 5

8. immunotherapy food allergies, eczema, urticaria, allergic
bronchopulmonary aspergillosis, hypersensitivity pneumonitis

systemic reaction


(319)
12 (.. 2530-2542) 42,810 systemic reaction
0.08

non-anaphylactic allergens peptide-based allergens IgE mast cells

Th1/Th2 response IL-10 allergen-specific IgG(320-321)
Cry-consensus peptide (CCP) Japanese cedar
pollinosis(322-323) rice-based edible vaccine peptides of Cry i1 Cry i2 Japanese cedar
pollinosis(324-325) Phl p2 Timothy grass pollen(326-327)

DNA-based immunization bacterial CpG monophosphoryl lipid A
Der f Th1 response (320, 328)

30

passive immunization specific IgG
ragweed immune gamma-globulin
(329) ragweed specific IgG (330)

IgE
mediated disease

[weak recommendation, low quality of
evidenee]







1.

2.

3. 3

4.

5. co-morbidity

(inferior turbinate reduction) (331) vidian neurectomy
, (332)
1 (333) (332) vidian neurectomy
vasomotor rhinitis
(334)

 ( ..)

31

septal surgery
sinus surgery



,
basement membrane hypertrophy

(335)

,

1. 3

2.



cryotherapy, submucosal electrocautery, partial turbinectomy, laser
turbinoplasty, radiofrequency turbinoplasty, submucous turbinate bone resection microdebrider-assisted inferior
turbinoplasty 3 ,


1.


2.
(336)

3. (direct cost, indirect cost, intangible cost)

4.
extraturbinal (extramucosal) techniques
intraturbinal(337)

32

(Alternative and Complimentary Medicine, ACM)

ACM .. 2540 4 10 ACM
.. 2533 50 ACM
8.7 .. 2533 16.6 .. 2540 (338) ACM
.. 2542 ACM 42 ACM
(ephedra), (Chinese herbal medicines) (339-340)
ACM

1. (Ayurvedic medicine)

2. (Homeopathy)

3. (Acupuncture)

4. (Steam inhalation) (Aromatherapy)

5. (Phytotherapy and Herbal medicines)
(Ayurvedic medicine) (341-342)

3

1.


2.



3.
(massage) (detoxification)

() , , , , , ,
, (343-344)
(Homeopathy) (345-347)

like
is cured by like law of similars-similia similibus curentur

 ( ..)

33

Taylor (348) randomized
controlled trial
(nasal airflow)
visual analogue scale
(Acupuncture)(349-350)



365
2000 (meridians) 14 ,
, , , , , , ,
, , , , ,

(351)
National Institutes of Health (NIH)(352)
,
(adjunctive treatment)(353)

(354-355) randomized single-blinded
(allergic asthma) (356)
(allergen immunotherapy) 419
allergic markers
3 3 68.7(356)
63(357)

(Special consideration)


1.


(volume distribution, 50, albumin ,
, )
(358-359) diffusion

34
(low molecular weight), ,
50-100
diazepam, xylocaine active transport(358)
18-30 (360)

(rhinitis medicamentosa)

(pregnancy rhinitis)





34 10-30
51 (360)
(anaphylaxis) (nasal cytology)

preeclampsia, vaginal hemorrhage, complicated labour
perinatal mortality, neonatal hypoxia,

3
/


(359, 361)
6

 ( ..)

35

6 (teratogenicity-risk classification)
(US-FDA)


(US-FDA Pregnancy Categories).(361)

36
7 (362-363)

 ( ..)

37

chlorpheniramine tripelennamine loratadine cetirizine
B 2 3
(withdrawal risk)

3

(first-pass metabolism)
B budesonide

C (phenylephrine), (naphazoline,
tetrahydrozoline) (oxymetazoline, xylometazoline)
pseudoephedrine pseudoephedrine
case-control -gastroschisis)
oxymetazoline
35 irritability

Cromolym sodium B

Leukotriene modifiers zileuton (5-lipoxygenase pathway inhibitor) C montelukast
(CystLt1 receptors inhibitor) B
montelukast

Allergen immunotherapy maintenance



2.

6





2 desloratadine, cetirizine, loratadine, fexofenadine (363-364) levocetirizine(365)
loratadine, desloratadine fexofenadine
loratadine 0.01 4
(364)

38

1 brompheniramine, chlorpheniramine , diphenhydramine
irritability(366)

pseudoephedrine 0.4-0.6
60 .(367)
24 (368-369)




antileukotriene zileuton
tumourgenicity (370)

cromones (370)

ketotifen (370)

3.

(371) 2
1

drug-disease interaction drug-drug interaction ipratropium bromide
,

4. (14, 372)

2 1
antileukotrienes, ipratropium bromide , sodium cromoglycate ephedrine
pseudoephedrine ( ephedrine 10
pseudoephedrine 150 (World-AntiDoping-Programe 2010)(372),

 ( ..)

39

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2.



3.


4.


5.


6.




7.



8.



9.




10.

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 ( ..)

23.



24.


25.




26.


27.



28.


29.


30.



31.


32.


33.


34.


35.

41

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((14) Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic Rhinitis and
its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and
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