## 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**.
**Gold-standard references:** Dhingra *Diseases of Ear, Nose and Throat*; Scott-Brown’s
*Otorhinolaryngology and Head & Neck Surgery*; Cummings *Otolaryngology*. ### Etiology **Inhalant
allergens:** House dust mites, pollens, 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 **Intermittent:** Symptoms
<4 days/week or <4 weeks. **Persistent:** Symptoms >4 days/week and >4 weeks. **Mild:** Normal sleep
and daily activities. **Moderate–Severe:** Sleep disturbance, impaired activities, troublesome symptoms.
### Pathophysiology **Sensitization phase:** Allergen → APC → Th2 cells → B cells → IgE → mast cells.
**Early phase:** Histamine, leukotrienes, prostaglandins cause sneezing, itching, watery rhinorrhea.
**Late phase:** Eosinophilic inflammation causes persistent nasal obstruction and mucosal edema. ###
Clinical Features **Classical tetrad:** - Sneezing - Watery rhinorrhea - Nasal obstruction - Nasal itching
**Associated:** Itchy watery eyes, postnasal drip, cough, hyposmia, headache, fatigue. ### Signs
**Allergic facies:** Open-mouth breathing, long face, allergic shiners. **Allergic salute:** Transverse nasal
crease due to frequent rubbing. **Anterior rhinoscopy:** Pale bluish edematous inferior turbinates with thin
watery secretions. ### Investigations - Peripheral eosinophil count - Nasal smear for eosinophils - Serum
IgE - **Skin prick test (most useful)** - CT PNS if sinusitis or polyps suspected - Pulmonary function tests if
asthma suspected ### Differential Diagnosis - Viral rhinitis - Vasomotor rhinitis - Chronic rhinosinusitis -
Deviated nasal septum - Nasal polyposis - CSF rhinorrhea ### Complications - Chronic sinusitis - Nasal
polyps - Otitis media with effusion - Eustachian tube dysfunction - Sleep disturbance - Worsening of
bronchial asthma ### Management **Principles:** Allergen avoidance, pharmacotherapy, immunotherapy,
surgery when indicated. #### Allergen Avoidance - Wash bedding weekly in hot water - Use mattress and
pillow covers - Remove carpets and heavy curtains - Reduce indoor humidity - Keep windows closed
during high-pollen periods - Avoid pets if sensitized #### Pharmacotherapy **Antihistamines:** Cetirizine,
levocetirizine, loratadine, fexofenadine. **Intranasal corticosteroids (most effective):** Fluticasone,
mometasone, budesonide, beclomethasone. **Intranasal antihistamines:** Azelastine, olopatadine.
**Decongestants:** Xylometazoline or oxymetazoline for not more than 5–7 days. **Leukotriene
antagonist:** Montelukast, especially if asthma is associated. ### Immunotherapy **Indications:**
Persistent symptoms despite treatment, identifiable allergen, desire to reduce long-term medication.
**Types:** Subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). ### Surgical
Treatment **Indications:** Inferior turbinate hypertrophy, nasal polyps, deviated septum, chronic sinusitis.
**Procedures:** Inferior turbinate reduction, submucosal diathermy, radiofrequency turbinate reduction,
septoplasty, FESS. ### Important Exam Points - **Most useful diagnostic test:** Skin prick test - **Most
effective treatment:** Intranasal corticosteroid spray - **Characteristic finding:** Pale bluish edematous
inferior turbinates - **Common associated disease:** Bronchial asthma ### Conclusion Allergic rhinitis is a
**common IgE-mediated inflammatory disease of the nasal mucosa** presenting with **sneezing, watery
rhinorrhea, nasal obstruction, and itching**. Diagnosis is mainly **clinical with support from skin prick
testing**, and the cornerstone of treatment is **allergen avoidance and intranasal corticosteroids**, with
immunotherapy and surgery reserved for selected patients.