Allergy rhinitis

B Y :

P R I M A D H I T Y O , S . K E D

R E Z D Y T O F A N , S . K E D

Allergy Rhinitis

Background

Allergic rhinitis is characterized by inflammation of the nasal passages and subsequent sneezing, nasal congestion, and rhinorrhea.

The disease course is chronic and relapsing.

Epidemiology

Incidence and Prevalence:

Allergic rhinitis affects more than 20% of the population in the western countries, with an incidence of 10 in 100,000 children and 15 in 100,000 adults.

In the U.S., 15,000 to 25,000 in 100,000 people are affected.

Demographics:

Allergic rhinitis occurs mostly in people under age 20 but can affect persons of any age.

Women are affected more commonly than men.

Seasonal Perrenial

Pollens, especially from grasses, trees, and weeds, and some outdoor molds ( eg, Alternaria , Botrytis , Fusarium , Mucor , and Cladosporiumspecies)

Dust mites

Animal dander and hair; allergens originate from the skin, urine, and saliva

Cockroaches

Molds ( eg , Penicillium , Aspergillus , Alternaria , and Cladosporium species) that grow in damp indoor areas or are blown into the house.

Certain foods, such as apples, celery, and nuts, in some patients who are sensitive to birch pollen; foods rarely cause chronic rhinitis, but rhinitis may be part of an acute anaphylactic reaction to food

Cigarette smoke

Nonspecific environmental pollutants

Causes

Risk factors

Family history of allergic rhinitis or another allergic disorder

Coexisting allergies ( eg , asthma in adults or children , atopic dermatitis )

Certain occupations, such as baking, which involves exposure to yeast molds (Saccharomyces species); agriculture or food processing involving contact with castor beans, which contain ricin, a very strong sensitizer to future allergic response; and plastic and foam work involving exposure to isocyanates

Associated disorders

Asthma in adults or children

Atopic dermatitis

Serous otitis media

Chronic sinusitis

Allergic conjunctivitis

Diagnosis

Symptoms of nasal congestion; sneezing; rhinorrhea; and itching of the nose, palate, and pharynx lasting more than 10 days and the observation of a pale, edematous nasal mucosa are suggestive of allergic rhinitis.

The presence of itching is characteristic of allergic rhinitis as opposed to other types of rhinitis.

Recurrence or chronicity of symptoms and absence of fever point to allergic rhinitis rather than upper respiratory tract infection.

The diagnosis can be confirmed by a positive skin prick test or radioallergosorbent test result.

Clinical Presentation

Onset of symptoms typically occurs during childhood or adolescence.

Characteristic symptoms include the following: Paroxysmal sneezing Rhinorrhea Nasal congestion Decreased sense of smell and taste Itching of the nose, palate, pharynx, eyes, and sometimes the ears Sore throat caused by postnasal drip

Symptoms of seasonal allergic rhinitis are much more pronounced in the spring and fall due to grass and weed pollens.

Symptoms that worsen indoors and upon exposure to pets are indicative of perennial allergic rhinitis.


Other historical presentations:

History of atopic dermatitis or food allergies

Family history of allergic rhinitis or similar symptoms


Signs:

Edematous, blanched nasal mucosa

Clear nasal secretions

Mouth breathing caused by nasal congestion

Dark circles under the eyes ('allergic shiners')

Nasal polyps may be present, although these also can occur

in patients with nonallergic rhinitis or alone with no

apparent underlying cause.

Clinical Presentations

Other physical examination factors:

The 'allergic salute' (wiping the nose upward with the palm of the hand) is characteristic of allergic rhinitis in children and, in severe cases, can lead to the formation of a transverse nasal crease

The nasal allergic response may be associated with inflamed or edematous conjunctivae with punctuate papules or with palatal inflammation

Bronchial wheezing may indicate asthma in adults or children , which often accompanies allergic rhinitis

Eczema may accompany allergic rhinitis

Diagnostic Testing

Laboratory workup often is unnecessary if the diagnosis is apparent based on the history and physical examination findings.

Skin prick testing often will confirm allergy to a particular inhalant and/or food

Intradermal skin testing may be performed to identify allergens if a skin prick test result is negative or equivocal and the clinical presentation is suggestive of allergic rhinitis

Diagnostic Testing

Nasal smear often will show large numbers of eosinophils in patients with allergic rhinitis, whereas the presence of neutrophils suggests infection

Radioallergosorbent testing usually detects elevated total and specific serum immunoglobulin (Ig) E levels in patients with allergic rhinitis; peripheral blood eosinophil counts are not useful in diagnosis

Office spirometry is reserved for patients in whom coexisting small airway disease (eg , asthma in adults or children ) is suspected

If chronic sinusitis is suspected, computed tomography (CT) scan of the sinuses should be obtained

Differential Diagnosis

Upper Respiratory Tract Infection

Upper respiratory tract infections in adults or children are self limited

infections usually caused by viruses

Features include clear to purulent rhinorrhea; sneezing; inflamed, red nasal mucosa; fever; arthralgia; myalgia; and sore throat

Symptoms typically last for 5 to 14 days

The diagnosis usually is apparent from the clinical history and physical examination findings


Nonallergic rhinitis

Nonallergic rhinitis is triggered by various environmental factors, such as strong odors, pollution, and other irritants

The condition usually is perennial

Features include nasal congestion, headaches, and often clear rhinorrhea

Nasal polyps are common


Rhinitis medicamentosa:

Occurs when nonprescription topical decongestants are used excessively

Patients have a history of chronic use of nasal decongestants or cocaine

Severe nasal congestion is present

The nasal mucosa usually is very red

Treatment (Summary Approach)

The goals of management of patients with allergic rhinitis are to identify the causative allergen(s) so that exposure can be avoided and to reduce symptoms to a level acceptable to the patient.

Patients should be advised about lifestyle changes (environmental control measures) that will help avoid or reduce exposure to allergens.


Intranasal corticosteroids ( eg , beclomethasone, budesonide, flunisolide , fluticasone ) are very effective, controlling all of the main symptoms of allergic rhinitis, and should be considered firstline therapy, especially in patients with chronic allergic rhinitis.

Corticosteroids can be used alone or in combination with an antihistamine or decongestant; combination therapy is effective in preventing recurrent sinusitis and postnasal drip–induced cough and is suitable for patients with severe nasal congestion.

Corticosteroids also may be helpful in treating acute episodes of severe congestion or sinus ostial blockage secondary to allergy. Oral or injected (systemic) steroids rarely are required and are not recommended for treatment of seasonal allergic rhinitis


Intranasal antihistamines ( eg, azelastine), which have the advantage of helping to relieve nasal congestion, also should be considered and are particularly effective when the allergen exposure is limited or short term. Intranasal antihistamines can be used concomitantly with intranasal corticosteroids and decongestants if necessary.


Ipratropium is a useful adjunct for controlling profuse rhinorrhea.

Oral antihistamines, particularly second-generation, non-sedating agents ( eg, cetirizine , fexofenadine , loratadin), are considered secondline therapy and are very effective in controlling most symptoms of allergic rhinitis,

Oral decongestants, such as pseudoephedrine , may be used concomitantly; combination antihistamine-decongestantpreparations are available.

Sedating oral antihistamines ( eg , promethazine or chlorpheniramine ) are less expensive than nonsedatingantihistamines and can be used when sedation is not a problem for the patient but are associated with a high risk of cognitive dysfunction and anticholinergic (muscarinic) adverse effects.


Montelukast , a leukotriene-receptor antagonist, is an alternative to oral antihistamines, but monotherapy usually only results in moderate improvement in symptoms.

Intranasal cromolyn sodium is considered thirdlinetherapy and is suitable for patients with mild to moderate allergic rhinitis and children. However, cromolyn is used primarily for prophylaxis and should be administered before exposure to a known allergen.


Immunotherapy is reserved for patients with severe, treatment-refractory allergic rhinitis who experience symptoms during most of the year.

Subcutaneous injections or sublingual oral therapy are used most commonly. A weekly treatment buildup period of 3 to 4 months is required followed by continuous monthly maintenance therapy for 3 to 5 years.

Clinical benefits may be sustained for years after discontinuation of treatment.

Follow-up

Monitoring

Patients who remain symptomatic and require medication should have regular follow-up visits

Prognosis

Allergic rhinitis is a chronic condition that usually is lifelong, although symptoms can decrease with age

The prognosis is affected adversely by other medical conditions, such as asthma in adults or children , and by exposure to perennial allergens, such as dust mites and molds

Complication

Epistaxis

Serous otitis media

Secondary sinusitis

Facial malformations in children with longstanding allergic rhinitis and severe nasal congestion

Nasal speech

Eustachian tube dysfunction

Increased susceptibility to upper respiratory tract infection in adults and children

Allergic conjunctivitis

Increased susceptibility to or exacerbation of asthma

Patient education

Patients with allergic rhinitis should be strongly encouraged to quit smoking and to avoid exposure to allergens to the extent possible

Patients with seasonal allergic rhinitis should be advised to keep doors and windows closed and use air conditioning, with special filters if possible, at home and in vehicles; patients also may need to alter outdoor activity depending on the time of year

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Health & Medicine

Allergy rhinitis