Everything You Ever Cared to Know About
Allergic Rhinitis
Nneoma Nwachuku, PGY2
April 16, 2015
M AY I
REMIND
YO U
Its
just
your
Burden of Allergic Rhinitis
Affects 10 to 30 percent of people in
the United States
2.4 billion dollars spent on
prescription and over-the counter
medication per year
Two million
lost school days per year; six million
lost workdays per year
A. Allergic Rhinitis
1. Describe the signs and symptoms of allergic rhinitis. (MK)
2. Obtain a history and perform a targeted physical
examination to diagnose allergic rhinitis. (PC, ICS, P)
Primary and Preventive Ambulatory Health Care 21
3. Describe the differential diagnosis of allergic rhinitis. (MK)
4. Counsel patients about the effect of environmental
allergens and initiate basic medical treatment for allergic
rhinitis. (P, PC, ICS)
Rhinitis
Rhinitis is an inflammation of the
nasal mucosa
Allergic rhinitis is an immunoglobulin
Emediated disease
Thought to occur after exposure to
indoor and outdoor allergens such as
dust mites, insects, animal danders,
molds, and pollens
Rhinitis
Important to
distinguish allergic
rhinitis from other
forms of rhinitis
because the
treatments for one
may not be as
effective for the other
Key is the history and
physical exam
Extensive differential
diagnosis
Differential Diagnosis
Side Note
Hormonal causes
include
Pregnancy
improves after
delivery
OCPS
Hypothyroidism
Drug induced
ACE-I
Methyldopa
Prazosin
Beta-blockers
Thorazine
Tocial nasal
decongestants
Aspirin
NSAIDs
Clues from History that Suggest
Allergic Rhinitis
Identifiable triggers
Seasonal variations
Constitutional symptoms (headache,
malaise, and fatigue
Onset at a young age (80% start
before the age of 20)
Family history of allergic symptoms
or asthma
Three Types of Allergic
Rhinitis
Seasonal
Tree, grass, and weed pollens, mold spores
Perennial
Mold spores, indoor allergens
Occupational
Laboratory animals, grains, coffee beans,
wood dust
Distinguish from irritants tobacco smoke,
cold air, formaldehyde, and hair spray
Signs and Symptoms
Excessive mucous
production
Congestion
Sneezing
Watery Eyes
Nasal pruritis
Ocular pruritis
Systemic symptoms
Asthma
Eczema
Chronic sinusitis
Physical Exam Findings
General
Constitutional symptoms suggest allergic rhinitis.
Mouth versus nose breathing is a symptom of chronic
congestion.
Eyes
Allergic shiners (i.e., dark areas under the eyes) suggest
allergic rhinitis.
Conjunctivitis suggests allergic rhinitis.
Ears
Air fluid levels can suggest chronic congestion.
Nose
A deviated or perforated septum and polyps are structural
causes of rhinitis.
Physical Exam Findings
Mouth
Enlarged tonsils and pharyngeal postnasal discharge are
associated with nonallergic rhinitis.
Neck
Lymphadenopathy suggests an infectious cause of rhinitis.
Chest
Allergic or atopic disease (e.g., asthma) supports the diagnosis
of allergic rhinitis.
Skin
Allergic or atopic disease (e.g., eczema) supports the
diagnosis of allergic rhinitis.
Diagnostic Testing
Percutaneous skin test
Allergen-specific immunoglobulin E
(IgE) antibody test
Less commonly used
Nasal provocation testing
Nasal cytology
Nasolaryngoscopy
Oral Antihistamines
Stabilize and
control nasal and
ocular symptoms
Less effective with
nasal congestion
(compared to
intranasal
corticosteroids)
Onset of action is
15-30minutes
Oral Antihistamines
First generation
medications (e.g.
Benadryl) had significant
side effects
Excessive drowsiness,
impaired school and work
performance
Second generation
includes:
Desloratidine (Clarinex);
Fexofenadine (Allegra),
Loratidine
Do not easily cross bloodbrain barrier
Intranasal Corticosteroids
Mainstay of
treatment for
allergic rhinitis
Decreasing influx
of inflammatory
cells, inhibit
release of
cytokines
Note: only
Budesonide
(Rhinocort) is
category B
Intranasal Corticosteroids
Side effects:
Headache,
epistaxis, nasal
dryness; restrict
growth in children
Nasal Decongestants
Acts on adrenergic
receptors and
produce local
vasoconstriction
Long-term use
leads to impaired
mucociliary
function; rebound
congestion
Intranasal Anticholinergics
Such as Atrovent
relief of excessive
rhinorrhea
BID dosing
For Severe to Persistent Symptoms
Consider Addition of:
Leukotriene Receptor Antagonist
(Singulair)
Minimal improvement
Intranasal Cromolyn
Inhibits degranulation of mast cells
Decreased effectiveness
Immunotherapy
Providing a small amount of allergen
administered over an extended period of time
with a maintenance period
Thanksand any questions?