Long Essay Question (LAQ): Allergic Rhinitis
Definition
Allergic rhinitis is an IgE-mediated inflammatory disorder of the nasal mucosa occurring after exposure to a
specific allergen in a sensitized individual, characterized by sneezing, watery rhinorrhea, nasal obstruction, and
nasal itching.
Etiology
Common Allergens
Inhalant Allergens
• House dust mites
• Pollens (grass, weeds, trees)
• Animal dander
• Fungal spores
• Cockroach allergens
Occupational Allergens
• Flour dust
• Cotton dust
• Wood dust
• Latex
Predisposing Factors
• Family history of atopy
• Asthma
• Eczema
• Environmental pollution
• Passive smoking
Classification
According to Duration
Intermittent
• Symptoms <4 days/week or <4 weeks
Persistent
• Symptoms >4 days/week and >4 weeks
According to Severity
Mild
• Normal sleep
• Normal daily activities
• No troublesome symptoms
Moderate–Severe
• Sleep disturbance
• Impaired daily activities
• Reduced work or school performance
• Troublesome symptoms
(ARIA classification)
Pathophysiology
Sensitization Phase
• Allergen is processed by antigen-presenting cells.
• Th2 lymphocytes stimulate B cells.
• B cells produce allergen-specific IgE.
• IgE binds to mast cells in the nasal mucosa.
Re-Exposure Phase
Early Phase (Minutes)
Mast cell degranulation releases:
• Histamine
• Leukotrienes
• Prostaglandins
Causing:
• Sneezing
• Itching
• Watery rhinorrhea
Late Phase (4–8 Hours)
Eosinophils and other inflammatory cells infiltrate the mucosa, leading to:
• Persistent nasal obstruction
• Mucosal edema
• Hyperreactivity of the nasal mucosa
Clinical Features
Symptoms (Classical Tetrad)
1. Sneezing – repeated paroxysmal sneezing, especially in the morning.
2. Rhinorrhea – profuse watery nasal discharge.
3. Nasal obstruction – intermittent initially, later persistent.
4. Nasal itching – involves nose, palate, throat, and eyes.
Associated Symptoms
• Itchy, watery eyes (allergic conjunctivitis)
• Postnasal drip
• Cough
• Hyposmia or anosmia
• Headache and fatigue
Signs
Allergic Facies
• Open-mouth breathing
• Long face
• Dark circles under eyes (allergic shiners)
Allergic Salute
Frequent upward rubbing of the nose producing a transverse nasal crease.
Nasal Examination
Anterior Rhinoscopy
• Pale, bluish, edematous inferior turbinates
• Thin watery secretions
• Congested but non-friable mucosa
Investigations
• Peripheral blood eosinophil count – supportive but not diagnostic.
• Nasal smear cytology – eosinophils in nasal secretions.
• Serum IgE – total IgE may be elevated; specific IgE identifies allergens.
• Skin prick test – most useful investigation; wheal-and-flare reaction in 15–20 minutes.
• CT PNS if sinusitis or polyps suspected.
• Pulmonary function tests if asthma suspected.
Differential Diagnosis
• Viral rhinitis – fever, malaise, short duration.
• Vasomotor rhinitis – no allergy or eosinophilia.
• Chronic rhinosinusitis – thick mucopurulent discharge.
• Deviated nasal septum – structural obstruction.
• Nasal polyposis – persistent obstruction with polypoidal masses.
• CSF rhinorrhea – unilateral clear watery discharge.
Complications
• Chronic sinusitis
• Nasal polyps
• Otitis media with effusion
• Eustachian tube dysfunction
• Sleep disturbance
• Worsening of bronchial asthma
• Impaired quality of life and school performance in children
Management
Principles
1. Allergen avoidance
2. Pharmacotherapy
3. Immunotherapy
4. Surgery for selected cases
Allergen Avoidance
• Wash bedding in hot water weekly.
• Use mattress and pillow covers.
• Remove carpets and heavy curtains.
• Reduce indoor humidity.
• Keep windows closed during high-pollen seasons.
• Wear masks outdoors.
• Avoid outdoor activities during peak pollen periods.
• Remove or minimize exposure to pets and keep them out of the bedroom.
Pharmacotherapy
Antihistamines
Preferred oral second-generation agents:
• Cetirizine
• Levocetirizine
• Loratadine
• Fexofenadine
They reduce sneezing, itching, and rhinorrhea but are less effective for severe nasal obstruction.
Intranasal Corticosteroids (Most Effective)
• Fluticasone
• Mometasone
• Budesonide
• Beclomethasone
Benefits:
• Best control of nasal obstruction.
• Reduce mucosal inflammation.
• Improve all major nasal symptoms.
Important Exam Point
Intranasal corticosteroids are the single most effective treatment for persistent allergic rhinitis.
Other Drugs
• Intranasal antihistamines: Azelastine, Olopatadine.
• Topical decongestants: Xylometazoline, Oxymetazoline (use for not more than 5–7 days).
• Leukotriene receptor antagonist: Montelukast, especially when associated with asthma.
Immunotherapy
Indications
• Symptoms persist despite optimal medical treatment.
• Identifiable specific allergen.
• Patient wishes to reduce long-term drug use.
Types
• Subcutaneous immunotherapy (SCIT) – gradually increasing doses of allergen extract.
• Sublingual immunotherapy (SLIT) – allergen tablets or drops under the tongue.
Advantages:
• Alters the natural course of allergic disease.
• May reduce progression to asthma.
Surgical Treatment
Surgery is not curative for allergy; it is performed for structural problems.
Indications
• Persistent inferior turbinate hypertrophy.
• Nasal polyps.
• Deviated nasal septum causing obstruction.
• Chronic sinusitis associated with allergic rhinitis.
Procedures
• Inferior turbinate reduction
• Submucosal diathermy
• Radiofrequency turbinate reduction
• Septoplasty
• Functional endoscopic sinus surgery (FESS) when indicated