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Allergic Rhinitis
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Allergic Rhinitis
, Hayfever, Allergic Shiner, Dennie's Lines, Allergic Salute
Epidemiology
Onset under age 30
Peak
Incidence
in childhood and adolescence
Most common chronic disease in United States
Affects 35 million Americans
Accounts for two million missed school days
Accounts for three million missed work days
Significantly affects quality of life
Pathophysiology
IgE mediated, type I
Antibody
-
Antigen
reaction to allergens
May take 4 years in a given region to be sensitized
Sequence of events
T
Lymphocyte
s and B
Lymphocyte
s release IgE
Antibody
Mast Cell
s in skin and mucosa with second exposure
Mast Cell
s degranulate
Release of histamine and chemotactic factors
Release of Prostaglandins and Leukotrienes
Response of Intravascular
Basophil
s
Late phase reactants release histamine over 12 hour
Associated Conditions
Atopy
Eczematous Dermatitis
Allergic Rhinitis
Asthma
Allergic Triad
Aspirin Allergy
Nasal Polyp
s
Asthma
History
Family History
Allergy
Asthma
Atopy
Other Risk Factors
Atopy
History of
Nasal Trauma
Medication use
NSAID
s
Antihypertensive Medications
Oral Contraceptive
s
Causes
Suspected
Environmental Allergen
s
Seasonal Allergens
Tree pollen (early spring)
Grass pollen (late spring)
Outdoor Molds (summer and fall)
Weed pollen (late summer to fall)
Perennial
Dust mite
s
Animal dander
Irritant
Cigarette
Smoke
Symptoms
Specific
Sneezing
Rhinorrhea
Nasal congestion
Pruritus
of the nose, eyes, and throat
Eye Tearing and
Conjunctiva
l discharge
Symptoms
Chronic Nasal Obstruction
Mouth Breathing
Snoring
Anosmia
Cough
Headache
Decreased Hearing
Halitosis
Symptoms
Gene
ralized due to chronicity of
Rhinitis
Irritability
Fatigue
Depression
Malaise
Weakness
Signs
Vitals
Rule out
Hypertension
associated with
Antihistamine
s
Nose
Use Nasal speculum with high power illumination
Examine before and after topical nasal
Decongestant
Mucosa
Pale blue
Boggy
Clear discharge
Ocular
Palpebral
Conjunctiva
pale and swollen
Bulbar
Conjunctiva
injected with clear discharge
Face
Allergic Shiners
Bluish purple rings around both eyes
Results from chronic mid-face venous congestion
Dennie's Lines
Skin folds under eyes
Allergic Salute
Transverse nasal crease from chronic nose rubbing
Mouth
High arched narrow
Palate
OR
Malocclusion from chronic mouth breathing
"Cobblestoning" of adenoids and
Tonsil
s
Ear (Rule out associated
Eustachian Tube Dysfunction
)
Dull, immobile
Tympanic Membrane
Conductive Hearing Loss
Sinus (Rule out
Sinusitis
)
Purulent discharge
Tender
Impaired transillumination
Labs
Skin Testing
Gold standard
RadioAllergoSorbent Test
(
RAST
Test)
Use if unable to skin test contraindicated as above
Nasal Smears
Eosinophil
s supportive of a diagnosis
Complete Blood Count
Normal
White Blood Cell Count
Increased
Eosinophil
s
IgE elevated
Differential Diagnosis
See
Rhinitis Causes
Management
Gene
ral Measures
Decrease
Environmental Allergen
s
Nasal Saline
Reduces symptoms and overall allergy medication use
Hermelingmeier (2012) Am J Rhinol Allergy 26(5): e119-25 [PubMed]
Non-Sedating Antihistamine
s
May be reasonable to use as first-line if taken as needed only occasionally
If regular use needed, then
Intranasal Steroid
s are preferred
Management
First-Line -
Intranasal Steroid
s
See
Intranasal Steroid
Effects
Effectively controls itching, sneezing and discharge
Moderately controls blockage symptoms
Small effect on impaired smell
Onset of action within hours, but maximal effect requires 2-4 weeks of continuous use
More effective than
Antihistamine
s
Yanez (2002) Ann Allergy Asthma Immunol 89(5): 479-84 [PubMed]
Agents (Pregnancy category C unless otherwise noted)
Age 2 years and older
Fluticasone furoate (Veramyst)
Mometasone (Nosonex)
Age 6 years and older
Beclomethasone (
Beconase
, Pregnancy category B)
Budesonide (
Rhinocort
)
Ciclesonide
(
Omnaris
)
Flunisolide
Age 12 years and older
Fluticasone propionate (
Flonase
)
Triamcinolone (Nasocort)
Management
First-Line -
Non-Sedating Antihistamine
s
Effects
Effectively controls itching and sneezing symptoms
Moderately controls discharge
Agents
Age 6 months and older
Cetirizine
(
Zyrtec
, Pregnancy category B)
Desloratadine (Clarinex, Pregnancy category C)
Fexofenadine
(
Allegra
, Pregnancy category C)
Age 2 years and older
Loratadine
(
Claritin
, Pregnancy category B)
Age 12 years and older
Levocetirizine (Xyzal, Pregnancy category B)
Management
Second-line agents
Overall symptoms persist
Intranasal
Antihistamine
s (pregnancy category C)
Azelastine (Astelin)
Safe at 5 years and older
Olopatadine
(Patanase)
Safe at 6 years and older
Leukotriene Antagonist
s (risk of
Major Depression
and
Suicide
)
Montelukast
(
Singulair
)
Pregnancy Category B
Safe for 6 months and older
Intranasal Cromolyn
(marginally effective)
Cromolyn (Nasalcrom)
Pregnancy category B
Safe at 2 years and older (but not recommended for children)
Rhinorrhea
predominates
See
Rhinitis
Nasal Saline
Intranasal
Ipratropium
(Intranasal
Atrovent
)
Effectively controls
Nasal Discharge
Ocular symptoms predominate
Ocular Allergy Preparations
(e.g.
Patanol
)
Management
Refractory management
Overall symptoms refractory to above measures
Refer to allergy
Allergy Test
ing
Omalizumab
(
Xolair
, approachs $1000 per dose)
Anti-
Immunoglobulin E
Antibody
Primarily indicated in
Asthma
, but also improves Allergic Rhinitis nasal symptoms
Casale (2001) JAMA 286(23): 2956-67 [PubMed]
Immunotherapy
Subcutaneous
Immunotherapy
(standard, broad variety of allergens available)
Sublingual Immunotherapy
(expensive, limited allergens available)
Severe acute exacerbation
Gene
rally avoid
Systemic Corticosteroid
s in Allergic Rhinitis (use
Inhaled Corticosteroid
s instead)
However, some consultants will use short-course systemic steroids in severe cases (but poor evidence)
Karaki (2013) Auris Nasus Larynx 40(3): 277-81 [PubMed]
Other measures
Petrolatum
Applied 4 times daily to inside of nares
Reduces nasal allergic symptoms
Schwetz (2004) Arch Otolaryngol Head Neck Surg 130 [PubMed]
References
Plaut (2005) N Engl J Med 353(18): 1934-44 [PubMed]
Price (2006) Prim Care Respir J 15(1): 58-70 [PubMed]
Scadding (2008) Clin Exp Allergy 38(1): 19-42 [PubMed]
Sur (2010) Am Fam Physician 81(12): 1440--6 [PubMed]
Sur (2015) Am Fam Physician 92(11): 985-92 [PubMed]
Wallace (2008) J Allergy Clin Immunol 122(2 suppl): S1-84 [PubMed]
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