Allergic Rhinitis David Pham, MD
Incidence and Prevalence • 10% - 20% of population; 40% of children • 30% - 60% of presenting at primary care • Onset: 8 to 12 years
Causes & Pathophysiology • Causes: Pollens, dust, mite, animal allergens, smoke / irritants (perfumes, soaps), changes in atmosphere • IgE-mediated, type I Antibody-Antigen reaction to allergens • May take 4 years in a given region to be sensitized; Seasonal or perennial • Sequence of events • T Lymphocytes and B Lymphocytes release Ig-E Antibody • Mast Cells: degranulate histamine and chemotactic factors
Clinical Presentation – History • Family History: Allergy, Asthma, Atopy • Personal history: Atopy; nasal Trauma, Medication use (NSAIDs, Antihypertensive meds, OCTs) • Seasonal Allergens: Tree pollen (early spring), Grass pollen (late spring), Outdoor Molds (summer and fall), Weed pollen (late summer to fall) • Perennial: Dust mites, Animal dander • Irritant: Cigarette Smoke
Clinical Presentation - Symptoms • Specific: Sneezing, rhinorrhea, nasal congestion, pruritus (nose, eyes, throat), eye tearing / conjunctival discharge • Chronic nasal obstruction: mouth, breathing, snoring, anosmia, cough, headache, decreased hearing, halitosis • Generalized due to chronic disease: irritability, fatigue, depression, malaise, weakness
Clinical Presentation - Signs • Nasal mucosa: pale blue, boggy, clear discharge • Ocular: Palpebral conjunctiva pale and swollen; Bulbar conjunctiva injected with clear discharge • Face: Allergic shiners, Dennie’s lines, allergic salute • Mouth: high arched narrow palate, malocclusion (chronic mouth breathing), “cobblestoning” of adenoids • Ear: dull, immobile, conductive hearing loss • Sinus: purulent discharge, tender, impaired transillumination
Differential Diagnosis • Infections (sinusitis; viral, bacterial, or fungal rhinitis) • Rhinitis medicamentosa (cocaine, sympathomimetic nasal drops) • Vasomotor rhinitis (e.g., secondary to air pollutants) • Septal obstruction (e.g., deviated septum), nasal polyps, nasal neoplasms • Systemic diseases (e.g., Wegener’s granulomatosis, hypothyroidism [rare])
Workup • Detailed history useful to identify culprit allergen. • Refractory cases may need labs: • Skin Testing: gold standard • RadioAllergoSorbent Test (RAST Test) • Nasal Smears: eosinophils supportive of a diagnosis • Complete Blood Count: increased Eosinophils • IgE elevated
Management: General Measures • Decrease environmental allergens • Nasal saline: Reduces symptoms and medication use
Management: First-line Medications • Non-sedating antihistamines: first-line if occasionally needed • Cetirizine, Desloratadine, Fexofenadine(> 6 mo) • Loratadine (>2 y/o) • Levocetirizine (> 12 y/o) • Intranasal Steroids: preferred if regularly needed > 2 y/o: Fluticasone furoate, Mometasone > 6 y/o: Beclomethasone, Budesonide, Ciclesonide, Flunisolide > 12 y/o: Fluticasone propionate, Triamcinolone
Management: Second-line Medications Overall symptoms persist • Intranasal Antihistamines: Azelastine (safe for 5 > y/o); Olopatadine (> 6y/o) • Leukotriene Antagonists: Montelukast (> 6 mo) • Intranasal Cromolyn (> 2 y/o, not recommended for children) Rhinorrhea predominates • Nasal Saline • Intranasal Ipratropium Ocular symptoms predominate • Ocular Allergy Preparations (Patanol)
Management: Refractory Cases Overall symptoms refractory to above measures • Refer to allergy • Allergy Testing • Omalizumab: expensive Severe acute exacerbation: • Systemic steroids (severe cases) Other measures: • Petrolatum (applied inside of nares, qid) reduces nasal allergic symptoms Ocular symptoms predominate • Ocular Allergy Preparations (Patanol)
Patient Education Nonpharmacologic Therapy • Maintain allergen-free environment by covering mattresses and pillows with allergen-proof casings, eliminating carpeting, eliminating animal products, and removing dust-collecting fixtures. • Use of air purifiers and dust filters is helpful. • Maintain humidity in the environment below 50% to prevent dust mites and mold. • Use air conditioners, especially in the bedroom. • Remove pets from homes of patients with suspected sensitivity to animal allergens. • Use of acupuncture to treat seasonal allergic rhinitis is controversial. A recent trial showed that acupuncture led to statistically significant improvement in disease-specific quality of life and antihistamine use measures after 8 weeks of treatment compared with sham acupuncture and with rescue medication alone.
References Centers for Disease Control and Prevention. (2017). Allergies and Hay Fever. Retrieved online from: https://www.cdc.gov/nchs/fastats/allergies.htm Ferri, F. F. (2019). Ferris clinical advisor 2020: 5 books in 1. S.l.: ELSEVIER. Liang, M. J., & Xu, R. (2016). Local Allergic Rhinitis and its Relation to Allergic Rhinitis. Otolaryngology,6(4). doi:10.4172/2161-119x.1000249 Moses, S. (2019, July 04). Allergic Rhinitis. Retrieved from https://fpnotebook.com/ENT/Nose/AlrgcRhnts.htm Naclerio, R. M., & Pawankar, R. (2014). Allergic Rhinitis. Asthma, 231-243. doi:10.1093/med/9780199918065.003.0018
