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Allergic Rhinitis

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Allergic Rhinitis, Hayfever, Allergic Shiner, Dennie's Lines, Allergic Salute

  • 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
  • Pathophysiology
  1. IgE mediated, 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
  • Associated Conditions
  1. Atopy
    1. Eczematous Dermatitis
    2. Allergic Rhinitis
    3. Asthma
  2. Allergic Triad
    1. Aspirin Allergy
    2. Nasal Polyps
    3. Asthma
  • History
  1. Family History
    1. Allergy
    2. Asthma
    3. Atopy
  2. Other Risk Factors
    1. Atopy
    2. History of Nasal Trauma
    3. Medication use
      1. NSAIDs
      2. Antihypertensive Medications
      3. Oral Contraceptives
  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
  • Symptoms
  • Specific
  1. Sneezing
  2. Rhinorrhea
  3. Nasal congestion
  4. Pruritus of the nose, eyes, and throat
  5. Eye Tearing and Conjunctival discharge
  • Symptoms
  • Chronic Nasal Obstruction
  1. Mouth Breathing
  2. Snoring
  3. Anosmia
  4. Cough
  5. Headache
  6. Decreased Hearing
  7. Halitosis
  1. Irritability
  2. Fatigue
  3. Depression
  4. Malaise
  5. Weakness
  • 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
  • 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
  • Differential Diagnosis
  1. See Rhinitis Causes
  • Management
  • General Measures
  1. Decrease Environmental Allergens
  2. Nasal Saline
    1. Reduces symptoms and overall allergy medication use
    2. Hermelingmeier (2012) Am J Rhinol Allergy 26(5): e119-25 [PubMed]
  3. Non-Sedating Antihistamines
    1. May be reasonable to use as first-line if taken as needed only occasionally
    2. If regular use needed, then Intranasal Steroids are preferred
  1. See Intranasal Steroid
  2. Effects
    1. Effectively controls itching, sneezing and discharge
    2. Moderately controls blockage symptoms
    3. Small effect on impaired smell
    4. Onset of action within hours, but maximal effect requires 2-4 weeks of continuous use
    5. More effective than Antihistamines
      1. Yanez (2002) Ann Allergy Asthma Immunol 89(5): 479-84 [PubMed]
  3. 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, Pregnancy category B)
      2. Budesonide (Rhinocort)
      3. Ciclesonide (Omnaris)
      4. Flunisolide
    3. Age 12 years and older
      1. Fluticasone propionate (Flonase)
      2. Triamcinolone (Nasocort)
  1. Effects
    1. Effectively controls itching and sneezing symptoms
    2. Moderately controls discharge
  2. Agents
    1. Age 6 months and older
      1. Cetirizine (Zyrtec, Pregnancy category B)
      2. Desloratadine (Clarinex, Pregnancy category C)
      3. Fexofenadine (Allegra, Pregnancy category C)
    2. Age 2 years and older
      1. Loratadine (Claritin, Pregnancy category B)
    3. Age 12 years and older
      1. Levocetirizine (Xyzal, Pregnancy category B)
  • 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 (risk of Major Depression and Suicide)
      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 (but not recommended for children)
  2. Rhinorrhea predominates
    1. See Rhinitis
    2. Nasal Saline
    3. Intranasal Ipratropium (Intranasal Atrovent)
      1. Effectively controls Nasal Discharge
  3. Ocular symptoms predominate
    1. Ocular Allergy Preparations (e.g. Patanol)
  • Management
  • Refractory management
  1. Overall symptoms refractory to above measures
    1. Refer to allergy
    2. Allergy Testing
    3. Omalizumab (Xolair, approachs $1000 per dose)
      1. Anti-Immunoglobulin EAntibody
      2. Primarily indicated in Asthma, but also improves Allergic Rhinitis nasal symptoms
      3. Casale (2001) JAMA 286(23): 2956-67 [PubMed]
    4. Immunotherapy
      1. Subcutaneous Immunotherapy (standard, broad variety of allergens available)
      2. Sublingual Immunotherapy (expensive, limited allergens available)
  2. Severe acute exacerbation
    1. Generally avoid Systemic Corticosteroids in Allergic Rhinitis (use Inhaled Corticosteroids instead)
      1. However, some consultants will use short-course systemic steroids in severe cases (but poor evidence)
      2. Karaki (2013) Auris Nasus Larynx 40(3): 277-81 [PubMed]
  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 [PubMed]
  • References
  1. Plaut (2005) N Engl J Med 353(18): 1934-44 [PubMed]
  2. Price (2006) Prim Care Respir J 15(1): 58-70 [PubMed]
  3. Scadding (2008) Clin Exp Allergy 38(1): 19-42 [PubMed]
  4. Sur (2010) Am Fam Physician 81(12): 1440--6 [PubMed]
  5. Sur (2015) Am Fam Physician 92(11): 985-92 [PubMed]
  6. Wallace (2008) J Allergy Clin Immunol 122(2 suppl): S1-84 [PubMed]