Allergic Rhinitis

Generally established by 6 years of age.

• Increased risk

– early introduction of formula (versus breast milk) or solids, mother smoking before child is 1 year old, heavy exposure to indoor allergens.
-Most perennial or mixed.
-Increased symptoms with greater exposure.
.-Diagnosis suggested by typical symptoms in absence of URI or structural abnormality (nasal congestion/pruritus, worse at night with snoring, mouth-breathing; watery, itchy eyes; postnasal drip with cough; possible wheezing; headache)

• Specific behaviors
– Allergic salute (rhinorrhea and nasal pruritus) ~ nasal crease
– Vigorous grinding of eyes with thumb and side of fist.

• History of symptoms
– Timing and duration (seasonal versus perennial)
– Exposures/settings in which symptoms occur
– Family history of allergic disease (atopy, asthma)
– Ask about perennial versus seasonal
– Seasonal allergies-usually need several seasons of exposure
– Food allergies more common (nuts, seafood) in young children (then skin, gastrointestinal, and, less often, respiratory)

• Physical examination
– Allergic shiners (venous stasis)-blue-gray-purple beneath lower eyelids; often
with Dennie lines-prominent symmetric skin folds
– Conjunctival injection, chemosis (edema), stringy discharge, “cobblestoning” of tarsal conjunctiva
– Transverse nasal crease (from allergic salute)
– Pale nasal mucosa, thin and clear secretions, turbinate hypertrophy,polyps
– Postnasal drip (posterior pharynx)
– Otitis media with effusion is common

• Differential diagnosis
– Nonallergic inflammatory rhinitis (no IgE antibodies)
– Vasomotor rhinitis (from physical stimuli)
• Neoplasms
• Asthma/Allergy
• Addison disease
• Collagen Vascular Disorders
• Parasites
– Nasal polyps (think of CF)
– Septal deviation
– Overuse of topical vasoconstrictors
– Neoplasms
– Vasculitides
– Granulomatous disorders (Wegener)

• Laboratory evaluation
– In vitro:
o Peripheral eosinophilia
o Eosinophils in nasal and bronchial secretions; more sensitive than blood eosinophils
o Increased serum IgE
o IgE-specific allergens:
~ RAST (radioallergosorbent testing)
~ Advantages:
Safety
Results not influenced by skin disease/medications
~ Major disadvantage: expensive; not as sensitive
~ Best use-extensive dermatitis, on medications that interfere with mast cell degranulation, high risk for anaphylaxis, cannot cooperate with skin tests
– In vivo-skin test:
o Skin prick/puncture –? if negative but history suggests atopy –? intradermal test
o Use appropriate allergens for geographic area plus indoor allergens.
o May not be positive before two seasons

• Treatment

-environmental control plus removal of allergen is most effective method
– Avoidance of biggest triggers-house dust mite, cat, cockroach, Dehumidifiers, HEPA-filtered vacuuming, carpet removal, pillow and mattress encasement
– Remove pets
-No smoking
– No wood-burning stoves/fireplaces.

• Pharmacologic control
Antihistamines (first-line therapy):
o First generation-sedating (diphenhydramine, chlorpheniramine, brompheniramine); cross blood-brain barrier-sedating
o Second generation (cetirizine, fexofenadine, loratadine)-nonsedating (now preferred drugs); easier dosing
o Oral antihistamines are more effective than cromolyn but significantly less than intranasal steroids; efficacy increased when combined with an intranasal steroid
– Intranasal corticosteroids-most effective medication, but not first-line:
o Effective for all symptoms
o Add to antihistamine if symptoms are more severe
o Less gastrointestinal absorption and safety with fiuticasone, mometasone,
budesonide
Chromones—cromolyn and nedocromil sodium:
o Least effective
o Very safe with prolonged use
– Decongestants-(alpha-adrenergic -+ vasoconstriction}-topical forms (oxymetazoline, phenylephrine) significant rebound when discontinued.
– Epinephrine-alpha and beta adrenergic effects; drug of choice for anaphylaxis
Immunotherapy:
o Administer gradual increase in dose of allergen mixture -+ decreases or eliminates person’s adverse response on subsequent natural exposure
o Major indication-duration and severity of symptoms are disabling in spite of routine treatment (for at least two consecutive seasons). This, however, is the treatment of choice for insect venom allergy.

• Complications of allergic Rhinitis.
Chronic sinusitis
– Asthma
Eustachian tube obstruction -+ middle ear effusion
– Tonsil/adenoid hypertrophy
– Emotional/psychological problems