ALLERGIC
RHINITIS
It is an IgE- mediated
immunologic
response of nasal
mucosa to airborne
allergens
• Types:
2 clinical types have been identified
1. SEASONAL in which symptoms appear in or
around a particular season. It is also called hay
fever.
2. Perennial in which symptoms appear throughout
the year
Epidemiology
• Allergic rhinitis affects a substantial number of
individuals, with estimates ranging from 10% to 30% of
the population in the US and other industrialized
countries. Studies suggest that it is more prevalent in
urban and industrialized areas compared to rural
settings.
• While AR can affect individuals of all ages, it is more
commonly diagnosed in children and
adolescents. Studies show that the prevalence increases
with age, with rates ranging from 5% in young children
to over 40% in adults.
Aetiology
• Inhalant allergens. They may be seasonal or perennial. Seasonal
allergens include pollens from trees, grasses and weeds. They vary
geographically. The knowledge of pollen appearing in a particular
area and the season in which they occur is important. Their
knowledge also helps in skin tests. Perennial allergens are present
throughout the year regardless of the season. They include molds,
dust mites, cockroaches and dander from animals. Dust includes
dust mite, insect parts, fibres and animal danders. Dust mites live
on skin scales and other debris and are found in the beddings,
mattresses, pillows, carpets and upholstery.
• Genetic predisposition plays an important part. Chances of children
developing allergy are 20 and 47%, respectively, if one or both
parents suffer from allergic diathesis
Pathogenesis
• Inhaled allergens produce specific IgE antibody in the genetically predisposed
individuals. This antibody becomes fixed to the blood basophils or tissue mast cells by
its Fc end . On subsequent exposure, antigen combines with IgE antibody at its Fab
end. This reaction produces degranulation of the mast cells with release of several
chemical mediators, some of which already exist in the preformed state while others
are synthesized afresh. These mediators are responsible for symptomatology of
allergic disease. Depending on the tissues involved, there may be vasodilation,
mucosal oedema, infiltration with eosinophils, excessive secretion from nasal glands
or smooth muscle contraction. A “priming affect” has also been described, i.e. mucosa
earlier sensitized to an allergen will react to smaller doses of subsequent specific
allergen. It also gets “primed” to other nonspecific antigens to which patient was not
exposed (Figure 30.3). Nonspecific nasal hyper-reactivity is seen in patients of allergic
rhinitis. There is increased nasal response to normal stimuli resulting in sneezing,
rhinorrhoea and nasal congestion. Clinically, allergic response occurs in two phases:
1. Acute or early phase. It occurs immediately within 5–30 min, after exposure to the
specific allergen and consists of sneezing, rhinorrhoea nasal blockage and/or
bronchospasm. It is due to release of vasoactive amines like histamine.
2. Late or delayed phase. It occurs 2–8 h after exposure to allergen without
additional exposure. It is due to infiltration of inflammatory cells—eosinophils,
neutrophils, basophil, monocytes and CD4 + T cells at the site of antigen deposition
causing swelling, congestion and thick secretion. In the event of repeated or
continuous exposure to allergen, acute phase symptomatology overlaps the late
Symptoms
The cardinal symptoms of seasonal nasal allergy include
• paroxysmal sneezing, 10–20 sneezes at a time
• nasal obstruction
• watery nasal discharge and itching in the nose. Itching may also involve eyes, palate
or pharynx.
• bronchospasm.
Symptoms of perennial allergy are not so severe as that of the seasonal type. They
include frequent
• colds
• persistently stuffy nose
• loss of sense of smell due to mucosal oedema
• postnasal drip
• chronic cough and hearing impairment due to eustachian tube blockage or fluid in
the middle ear.
Signs of allergy may be seen in the nose, eyes, ears, pharynx or larynx.
• Nasal signs include transverse nasal crease—a black line across the middle of dorsum of nose
due to constant upward rubbing of nose simulating a salute (allergic salute), pale and
oedematous nasal mucosa which may appear bluish. Turbinates are swollen. Thin, watery or
mucoid discharge is usually present.
• Ocular signs include oedema of lids, congestion and cobblestone appearance of the
conjunctiva, and dark circles under the eyes (allergic shiners).
• Otologic signs include retracted tympanic membrane or serous otitis media as a result of
eustachian tube blockage.
• Pharyngeal signs include granular pharyngitis due to hyperplasia of submucosal lymphoid
tissue. A child with perennial allergic rhinitis may show all the features of prolonged mouth
breathing as seen in adenoid hyperplasia.
• Laryngeal signs include hoarseness and oedema of the vocal cords
Differential diagnosis
•Vasomotor rhinitis - noninflammatory rhinitis that can be triggered by a change in
temperature, odors, or humidity
•Infectious rhinitis - viral or bacterial infections, most commonly seen in the
pediatric population
•Cerebrospinal fluid leak - clear rhinitis refractory to treatment
•Non-allergic rhinitis with eosinophilia syndrome (NARES) - infiltration of
eosinophils in nasal tissue without allergic sensitization
•Chemical rhinitis - exposure to chemicals through occupation, household
chemicals, sport/leisure exposure
•Rhinitis of pregnancy and hormonally-induced rhinitis
•Drug-induced rhinitis - e.g., NSAIDs, ACE inhibitors, nasal decongestants, cocaine
•Autoimmune, granulomatous, and vasculitic rhinitis - Granulomatosis with
polyangiitis, sarcoidosis, etc.
•Nasal polyposis
•Nasopharyngeal neoplasm
•Sickle cell anemia - in a young child presenting with nasal polyposis and well-
controlled asthma, sweat chloride testing is the appropriate next step in
management to rule out cystic fibrosis.
Investigations
• Total and differential count
• Nasal smear
• Skin tests
• Specific IgE measurements
• Nasal provocation test
Treatment
1. Avoidance of allergen
2. Treatment with drugs
• Anti histamines
• Sympathomimetic drugs
• Corticosteroids
• Sodium cronoglycate
• Anticholinergics
• Leukotriene receptor antagonists
• Anti IgE
1. Immunotherapy
Complications
• Recurrent sinusitis
• Formation of nasal polypi
• Serous otitis media
• Orthoodontic problems
• Bronchial asthma