Otolaryngology Book

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Allergic Rhinitis

Aka: Allergic Rhinitis, Hayfever, Allergic Shiner, Dennie's Lines, Allergic Salute
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  1. Epidemiology
    1. Onset under age 30
    2. Peak Incidence in childhood and adolescence
    3. Most common chronic disease in United States
      1. Affects 35 million Americans
      2. Accounts for two million missed school days
      3. Accounts for three million missed work days
    4. Significantly affects quality of life
  2. Pathophysiology
    1. Type I Antibody-Antigen reaction to allergens
    2. May take 4 years in a given region to be sensitized
    3. Sequence of events
      1. T Lymphocytes and B Lymphocytes release IgE Antibody
      2. Mast Cells in skin and mucosa with second exposure
      3. Mast Cells degranulate
      4. Release of histamine and chemotactic factors
        1. Release of Prostaglandins and Leukotrienes
        2. Response of Intravascular Basophils
        3. Late phase reactants release histamine over 12 hour
  3. Associated Conditions
    1. Atopy
      1. Eczematous Dermatitis
      2. Allergic Rhinitis
      3. Asthma
    2. Allergic Triad
      1. Aspirin Allergy
      2. Nasal Polyps
      3. Asthma
  4. Family History
    1. Allergy
    2. Asthma
    3. Atopy
  5. History
    1. Atopy
    2. History of nasal trauma
    3. Medication use
      1. NSAIDs
      2. Antihypertensive Medications
      3. Oral Contraceptives
  6. Causes: Suspected environmental allergens
    1. Seasonal Allergens
      1. Tree pollen (early spring)
      2. Grass pollen (late spring)
      3. Outdoor Molds (summer and fall)
      4. Weed pollen (late summer to fall)
    2. Perennial
      1. Dust mites
      2. Animal dander
    3. Irritant
      1. Cigarette Smoke
  7. Symptoms: Specific
    1. Sneezing
    2. Rhinorrhea
    3. Nasal congestion
    4. Pruritus of the nose, eyes, and throat
    5. Eye Tearing and Conjunctival discharge
  8. Symptoms: Chronic Nasal Obstruction
    1. Mouth Breathing
    2. Snoring
    3. Anosmia
    4. Cough
    5. Headache
    6. Decreased Hearing
    7. Halitosis
  9. Symptoms: Generalized due to chronicity of Rhinitis
    1. Irritability
    2. Fatigue
    3. Depression
    4. Malaise
    5. Weakness
  10. Signs
    1. Vitals
      1. Rule out Hypertension associated with Antihistamines
    2. Nose
      1. Use Nasal speculum with high power illumination
      2. Examine before and after topical nasal Decongestant
      3. Mucosa
        1. Pale blue
        2. Boggy
        3. Clear discharge
    3. Ocular
      1. Palpebral Conjunctiva pale and swollen
      2. Bulbar Conjunctiva injected with clear discharge
    4. Face
      1. Allergic Shiners
        1. Bluish purple rings around both eyes
        2. Results from chronic mid-face venous congestion
      2. Dennie's Lines
        1. Skin folds under eyes
      3. Allergic Salute
        1. Transverse nasal crease from chronic nose rubbing
    5. Mouth
      1. High arched narrow Palate OR
      2. Malocclusion from chronic mouth breathing
      3. "Cobblestoning" of adenoids and tonsils
    6. Ear (Rule out associated Eustachian Tube Dysfunction)
      1. Dull, immobile Tympanic Membrane
      2. Conductive Hearing Loss
    7. Sinus (Rule out Sinusitis)
      1. Purulent discharge
      2. Tender
      3. Impaired transillumination
  11. Labs:
    1. Skin Testing
      1. Gold standard
    2. RadioAllergoSorbent Test (RAST Test)
      1. Use if unable to skin test contraindicated as above
    3. Nasal Smears
      1. Eosinophils supportive of a diagnosis
    4. Complete Blood Count
      1. Normal White Blood Cell count
      2. Increased Eosinophils
    5. IgE elevated
  12. Differential Diagnosis
    1. See Rhinitis Causes
  13. Management: Initial first-line management
    1. Decrease Environmental Allergens
    2. Intranasal Steroids
      1. Effects
        1. Effectively controls itching, sneezing and discharge
        2. Moderately controls blockage symptoms
        3. Small effect on impaired smell
      2. Agents (Pregnancy category C unless otherwise noted)
        1. Age 2 years and older
          1. Fluticasone furoate (Veramyst)
          2. Mometasone (Nosonex)
        2. Age 6 years and older
          1. Beclomethasone (Beconase)
            1. Pregnancy category B
          2. Budesonide (Rhinocort)
          3. Ciclesonide (Omnaris)
          4. Flunisolide
        3. Age 12 years and older
          1. Fluticasone propionate (Flonase)
          2. Triamcinolone (Nasocort)
    3. Antihistamine
      1. Effects
        1. Effectively controls itching and sneezing symptoms
        2. Moderately controls discharge
      2. Agents (Pregnancy category C unless otherwise noted)
        1. Age 6 months and older
          1. Cetirizine (Zyrtec)
            1. Pregnancy category B
          2. Desloratadine (Clarinex)
          3. Fexofenadine (Allegra)
        2. Age 2 years and older
          1. Loratadine (Claritin)
            1. Pregnancy category B
        3. Age 12 years and older
          1. Levocetirizine (Xyzal)
            1. Pregnancy category B
  14. Management: Second-line agents
    1. Overall symptoms persist
      1. Intranasal Antihistamines (pregnancy category C)
        1. Azelastine (Astelin)
          1. Safe at 5 years and older
        2. Olopatadine (Patanase)
          1. Safe at 6 years and older
      2. Leukotriene antagonists
        1. Montelukast (Singulair)
          1. Pregnancy Category B
          2. Safe for 6 months and older
      3. Intranasal Cromolyn (marginally effective)
        1. Cromolyn (Nasalcrom)
          1. Pregnancy category B
          2. Safe at 2 years and older
    2. Rhinorrhea predominates
      1. See Rhinitis
      2. Saline Nasal Drops
      3. Intranasal Ipratropium (Intranasal Atrovent)
        1. Effectively controls Nasal discharge
    3. Ocular symptoms predominate
      1. Ocular Allergy Preparations (e.g. Patanol)
  15. Management: Refractory management
    1. Overall symptoms refractory to above measures
      1. Refer to allergy
      2. Allergy Testing
      3. Consider Immunotherapy
    2. Severe acute exacerbation
      1. Systemic steroids (severe cases)
    3. Other measures
      1. Petrolatum
        1. Applied 4 times daily to inside of nares
        2. Reduces nasal allergic symptoms
        3. Schwetz (2004) Arch Otolaryngol Head Neck Surg 130
  16. References
    1. Plaut (2005) N Engl J Med 353(18): 1934-44
    2. Price (2006) Prim Care Respir J 15(1): 58-70
    3. Scadding (2008) Clin Exp Allergy 38(1): 19-42
    4. Sur (2010) Am Fam Physician 81(12): 1440--6
    5. Wallace (2008) J Allergy Clin Immunol 122(2 suppl): S1-84

Atopic rhinitis (C0002103)

Definition (NCI) Allergic rhinitis with a positive skin prick test (SPT equal or greater than 3 mm) to any allergen. (World Allergy Organization)
Concepts Disease or Syndrome (T047)
SnomedCT 38103000
English RHINITIS ALLERGIC ATOPIC, RHINITIS, ATOPIC, Atopic rhinitis, Rhinitis allergic atopic, Atopic rhinitis (disorder), Atopic Rhinitis
Dutch atopische allergische rhinitis, atopische rhinitis
French Rhinite allergique atopique, Rhinite atopique, RHINITE ALLERGIQUE ATOPIQUE
German Rhinitis allergisch atopisch, atopische Rhinitis, RHINITIS ALLERGISCH
Italian Rinite atopica, Rinite allergica atopica
Portuguese Rinite atópica, Rinite alérgica atópica, RINITE ALERGICA ATOPICA
Spanish Rinitis atópica, Rinitis alérgica atópica, RINITIS ALERGICA ATOPICA, rinitis atópica, rinitis atópica (trastorno)
Japanese アトピー性アレルギー性鼻炎, アトピー性鼻炎, ｱﾄﾋﾟｰｾｲｱﾚﾙｷﾞｰｾｲﾋﾞｴﾝ, ｱﾄﾋﾟｰｾｲﾋﾞｴﾝ
Czech Atopická rýma, Rýma alergická atopická
Hungarian Atopiás rhinitis, Allergiás rhinitis, atopiás
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Hay fever (C0018621)

Definition (MEDLINEPLUS)

Each spring, summer, and fall, trees, weeds and grasses release tiny pollen grains into the air. Some of the pollen ends up in your nose and throat. This can trigger a type of allergy called hay fever.

Symptoms can include

  • Sneezing, often with a runny or clogged nose
  • Coughing and postnasal drip
  • Itching eyes, nose and throat
  • Dark circles under the eyes

Taking medicines, using nasal sprays and rinsing out your nose can relieve symptoms. Allergy shots can help make you less sensitive to pollen and provide long-term relief.

NIH: National Institute of Allergy and Infectious Diseases
Definition (NCI) Allergic rhinitis caused by outdoor allergens.
Definition (CSP) seasonal variety of allergic rhinitis, marked by acute conjunctivitis with lacrimation and itching; regarded as an allergic condition triggered by specific allergens.
Definition (MSH) Allergic rhinitis that occurs at the same time every year. It is characterized by acute CONJUNCTIVITIS with lacrimation and ITCHING, and regarded as an allergic condition triggered by specific ALLERGENS.
Concepts Disease or Syndrome (T047)
MSH D006255
ICD9 477.0
ICD10 J30.1, J30
SnomedCT 70369002, 278515004, 444316004, 21719001, 367498001, 300910009, 195818002, 155537009, 266386004, 155536000
English Pollenosis, Hayfever, SEASONAL ALLERGIC REACTION, SEASONAL ALLERGIES, Fever, Hay, HAY FEVER, HAYFEVER, Allergic rhinitis - pollens, pollenosis, allergic rhinitis due to pollen (diagnosis), allergic to pollens, spasmodic rhinorrhea, spasmodic rhinorrhea (diagnosis), seasonal allergic rhinitis, hay fever (diagnosis), allergic rhinitis due to pollen, seasonal allergies, hay fever, allergy to pollen, allergy to pollen (history), Pollen allergy, RHINITIS ALLERGIC SEASONAL, ALLERGY TO POLLEN, ALLERGY SEASONAL, pollen allergy, allergy to pollens, Rhinitis due to pollen, Seasonal allergy (disorder), Seasonal allergy, Rhinitis, Allergic, Seasonal [Disease/Finding], seasonal allergy, allergies pollen, fever hay, allergy pollen, Allergic rhinitis due to pollen, Seasonal allergic rhinitis, Spasmodic rhinorrhea, Allergic rhinitis due to pollens, Allergy to pollen, Allergic rhinitis due to pollen (disorder), Allergy to pollen (disorder), Seasonal allergic rhinitis (disorder), Spasmodic rhinorrhoea, pollen; allergy, pollinosis, allergic; rhinitis, due to pollen, allergic; rhinitis, seasonal, due to pollen, allergy; pollen, rhinitis; allergic, due to pollen, rhinitis; allergic, seasonal, due to pollen, rhinitis; allergic, seasonal, rhinorrhea; spasmodic, spasmodic; rhinorrhea, Hay fever, Hay fever - pollens, Pollinosis (& allergic rhinitis due to pollens), Seasonal allergic rhinitis (disorder) [Ambiguous], Seasonal allergic rhinitis [Ambiguous], Hay Fever, Rhinitis, Allergic, Seasonal, Pollinosis, Pollen Allergy, Allergic Rhinitides, Seasonal, Allergic Rhinitis, Seasonal, Allergies, Pollen, Pollen Allergies, Pollinoses, Rhinitides, Seasonal Allergic, Rhinitis, Seasonal Allergic, Seasonal Allergic Rhinitis, Allergy, Pollen, Seasonal Allergic Rhinitides, hayfever
German HEUFIEBER, jahreszeitbedingte allergische Rhinitis, Pollenallergie, Rhinitis infolge von Pollen, Allergische Rhinopathie durch Pollen, Jahreszeitbedingte Allergie, Heufieber, Heuschnupfen, Pollinosis, Rhinitis, saisonale allergische, Pollinose
Italian Allergia stagionale, Rinite allergica da pollini, Allergia al polline, Pollinosi, Febbre da fieno, Allergia ai pollini, Rinite allergica stagionale
Dutch allergische rhinitis door pollen, hooikoorts, pollinose, seizoensgebonden allergische rhinitis, pollenallergie, allergie; pollen, allergisch; rinitis, door pollen, allergisch; rinitis, seizoengebonden, door pollen, pollen; allergie, rinitis; allergisch, door pollen, rinitis; allergisch, seizoengebonden, door pollen, rinitis; allergisch, seizoengebonden, rinorroe; spasmodisch, spasmodisch; rinorroe, Allergische rinitis door pollen, seizoensgebonden allergie, Allergische conjunctivitis, Allergische rhinitis, Conjunctivitis, allergische, Hooikoorts, Rhinitis, allergische, Rhinitis, allergische seizoensgebonden
French Rhinite allergique due au pollen, Allergie aux pollens, RHUME DES FOINS, Allergie saisonnière, Coryza allergique périodique, Coryza spasmodique périodique, Rhinite allergique périodique, Rhinite spasmodique périodique, Rhume des foins, Allergie au pollen, Maladie de Bostock, Pollinose, Rhinite allergique saisonnière
Portuguese Alergia ao pólen, Febre dos fenos, Rinite alérgica por pólen, Rinite alérgica sazonal, FEBRE DOS FENOS, Alérgias próprias das estações do ano, Febre do Feno, Rinite Alérgica Sazonal, Polinose, Alergia a Pólen, Alergia ao Pólen
Spanish Rinitis alérgica estacional, Fiebre del heno, Rinitis alérgica por polen, Alergia al polen, Seasonal allergic rhinitis [Ambiguous], Pollinosis (& allergic rhinitis due to pollens), Allergic rhinitis due to pollens, Pollinosis, Seasonal allergic rhinitis, Hay fever - pollens, FIEBRE DEL HENO, alergia estacional, alergia estacional (trastorno), alergia al polen (trastorno), alergia al polen, fiebre del heno, polinosis, rinitis alérgica estacional (concepto no activo), rinitis alérgica estacional (trastorno), rinitis alérgica estacional, rinitis alérgica secundaria a alérgeno, rinorrea espasmódica, Alergia estacional, rinitis alérgica por polen (trastorno), rinitis alérgica por polen, Polinosis, Rinitis Alérgica Estacional, Rinitis Alergica Estacional, Alergia a Polen, Alergia al Polen, Fiebre del Heno
Japanese 季節性アレルギー, 花粉によるアレルギー性鼻炎, ｷｾﾂｾｲｱﾚﾙｷﾞｰ, ｷｾﾂｾｲｱﾚﾙｷﾞｰｾｲﾋﾞｴﾝ, ｶﾌﾝｼｮｳ, ｶﾌﾝﾆﾖﾙｱﾚﾙｷﾞｰｾｲﾋﾞｴﾝ, ｶﾌﾝｱﾚﾙｷﾞｰ, ｺｿｳﾈﾂ, 花粉アレルギー, 枯草熱, アレルギー性季節性鼻炎, 花粉症, アレルギー性鼻炎-季節性, 鼻炎-アレルギー性季節性, 季節的アレルギー性鼻炎, 季節性アレルギー性鼻炎, 鼻炎-アレルギー性-季節的
Swedish Rinit, allergisk, årstidsbunden
Czech polinóza, rinitida alergická sezónní, senná rýma, Alergická pylová rýma, Sezónní alergická rýma, Pylová alergie, Alergie na pyly, Polinóza, Sezónní alergie
Finnish Heinänuha
Russian RINIT ALLERGICHESKII SEZONNYI, SENNAIA LIKHORADKA, РИНИТ АЛЛЕРГИЧЕСКИЙ СЕЗОННЫЙ, СЕННАЯ ЛИХОРАДКА
Korean 화분에 의한 알레르기성 비염
Polish Nieżyt nosa alergiczny sezonowy, Gorączka sienna, Nieżyt nosa pyłkowy
Hungarian Pollenallergia, Pollinosis, Szezonális allergiás rhinitis, Szezonális allergia, Pollen okozta allergiás rhinitis, Szénanátha
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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