Allergic Rhinitis

Background

Definition: Inflammation of the nasal membranes in response to known or unknown allergen(s); also known as “hay fever” → rhinorrhea, sneezing, nasal congestion/pruritus
Pathophysiology: 1st exposure → production of allergen-specific IgE → IgE binds receptors on mast cells & basophils; subsequent exposures → allergen crosslinks IgE on cell surface → cellular activation (i.e., mast cell degranulation)
Epidemiology: Prevalence is increasing; highest in children and teens; currently affects >8% of US adults; accounts for >13 million US health care visits annually (cdc.gov/nchs)
Risk factors: Include ⊕ FHx of allergic disease (possibly mediated by genetics [multiple loci]), ↑ exposure to pollutants, dust mites, and early exposure to cigarette smoke (JACI 2011;128:816)
Complications: Nasal inflammation sx can affect QoL & productivity; additionally, ↑ incidence/severity of URIs (2/2 mucosal inflammation) & bacterial sinusitis (2/2 sinus obstruction) (Otolaryngol Head Neck Surg 2007;137:S1)
Comorbidities: 40% of pts w/ AR also have asthma; tx of AR → improved asthma sx & ↓ hospitalizations (JACI 2002;109:57); ocular sx occur in 50–70% of pts w/ AR (see “Eye Complaints”); also strongly assoc w/ AD (“atopic march”)

Evaluation

General approach: Establish sx severity & potential triggers, consider DDx & assess for comorbidities (OSA, asthma, atopy)
History: Assess sx, including functional (impaired sleep & work)
- Meds: Important to r/o rhinitis medicamentosa as cause of sx (see below); include OTC decongestants & nasal sprays, OCPs, ASA, NSAIDs, anti-HTN
- PMHx/Soc hx: Hx atopy (asthma, AD), OSA, environmental or food allergies, occupational hx, risk factors (above), current pregnancy, cocaine use

Allergic Rhinitis Triggers
Seasonal	Tree pollen (spring), grasses (summer), weeds (fall)
Perennial	Animal hair (cat, dog, etc.), dust mites, cockroaches (urban areas), mold
Occupational	Agricultural workers, animal lab workers, food services

Exam: HEENT + skin (atopic dermatitis) & lung (asthma) exam
- Eyes: Bilateral conjunctival hyperemia ± clear d/c (allergic conjunctivitis), infraorbital “shiners” (↑ venous stasis 2/2 nasal congestion)
- Ears: Serous otitis media (Eustachian tube dysfunction)
- Nose: Saddle-nose deformity (granulomatosis w/polyangiitis, or GPA) or septal deviation (trauma) or perforation (cocaine), pallor of mucosa, pallor/edema of turbinates; “allergic salute” (rubbing nasal tip upward w/ palm → supratip crease); polyps (chronic sinusitis, ASA Se)
Differential diagnosis: Up to 30% of rhinitis nonallergic
- Infectious: Acute viral rhinosinusitis, chronic rhinosinusitis (consider immunodeficiency)
- Medication-induced: S/e of ASA/NSAID, ACEI, PDE5, HCTZ, β-blockers; and OCPs (JACI 2006;16:148) rhinitis medicamentosa (“rebound” 2/2 chronic use of topical nasal decongestants, e.g., oxymetazoline; also seen w/ cocaine)
- Autoimmune: Churg–Strauss, GPA, sarcoid
- Idiopathic: Vasomotor rhinitis (nonallergic, noninfectious)
- Structural: Nasal polyps, deviated septum, adenoid hypertrophy
- Other: Pregnancy, assoc w/ menstrual cycle (2/2 ↑ circulating estrogen/progesterone)
WHO classification (JACI 2001;108:S147)
- Frequency: Intermittent (<4 d/wk or <4 wk) vs. persistent (>4 d/wk or >4 wk)
- Severity: Mod–severe (≥1 of the following: sleep disturbance, impaired school/work performance, impaired daily activities, troublesome sx) vs. mild (no significant sx)

Management

Allergen avoidance: Identify/avoid triggers when possible
- Dust mite: Humidity control, dust mite covers for bedding, HEPA vacuuming of carpeting
- Pollen: Avoid outdoors during AM (when pollen counts highest), use air conditioners when possible, don’t hang clothes out to dry
- For further allergen avoidance suggestions, see “Asthma”
Nasal irrigation: Beneficial for chronic rhinorrhea; may be used alone or as adjuvant; Neti pot superior to saline mist (advise pts to use sterile saline, risk of N. fowleri); may also be done w/ low-pressure irrigation squeeze bottle (AFP 2010;81:1440)
Pharmacotherapy: Multiple tx options; intranasal corticosteroids most effective for mod–severe disease; oral antihistamines reasonable for intermittent or milder disease; avoid topical nasal decongestants b/c of risk of rebound congestion & rhinitis medicamentosa
Intranasal therapy technique: Direct spray superiorly/laterally (“toward ipsilateral ear”)

Pharmacotherapy
Class	Example Rx & Notes
Intranasal corticosteroids (1st line for mod–severe disease)	Fluticasone (50 μg/spray): 2 sprays/nostril QD or 1 spray/nostril BID Can ↓ to 1 spray/nostril QD for maintenance; onset ~12 h, should be used consistently for ↑ efficacy Also effective in mixed rhinitis (e.g., irritant) S/e: Nasal irritation, epistaxis, bitter taste; systemic s/e rare No difference in efficacy w/in class (J Laryngol Otol 2003;117:843)
Oral antihistamines	Fexofenadine (OTC): 60 mg BID or 180 mg once daily Cetirizine 10 mg QD 2nd-generation preferred (↓ sedation, ↓ anticholinergic effects, although may be ↓ effective rhinorrhea tx) Faster onset, less effective than ICS for severe disease or nasal congestion; can be used PRN but more effective if used regularly Fexofenadine/loratadine/desloratadine less sedating, cetirizine more sedating Cetirizine and loratadine are category B for pregnancy
Nasal antihistamines	Azelastine 1–2 sprays/nostril BID or olopatadine 2 sprays/nostril BID Equal or superior efficacy to oral Rx for nasal sx; less effective than intranasal corticosteroids S/e: Bitter taste, somnolence May be given in combination with glucocorticoid sprays and oral antihistamines
Intranasal anticholinergics	Ipratropium (0.03%): 2 sprays/nostril BID–TID Good for ↓ rhinorrhea; not effective at ↓ congestion
Leukotriene receptor antagonists	Montelukast 10 mg PO QD; also effective in asthma (consider use in pts w/ both diseases); similar efficacy in AR to oral antihistamines

Other:
- Mast cell stabilizer (intranasal cromolyn): Can be used as ppx (take just before exposure → 4–8 h protection) or maintenance (best if started prior to exposure); less effective than intranasal corticosteroids
- Acupuncture: Nonpharmacologic therapy; may ↑ QoL and ↓ symptoms (Ann Allergy Asthma Immunol 2015:115:4)
- Oral decongestants: Pseudoephedrine: IR: 60 mg q4–6h; Extended release: 120 mg q12h or 240 mg QD (max 240 mg/24 h); unclear efficacy—may be no better than placebo; use only short term (5–7 d) (JACI In Practice 2015;3:5); S/e: HTN, insomnia, palpitations, urinary retention
When to Refer
- Allergy/immunology: For severe/refractory/recurrent sx; for allergen-specific IgE skin/serum testing; if dx uncertain; for treatment with sublingual immunotherapy (ragweed or grass pollen) or subQ immunotherapy (desensitization, “allergy shots,” often requires 3–5 y of tx) to alter immune response
- Otolaryngology: If suspect structural etiology (e.g., deviated septum, nasal obstruction)

USC IM

Table of Contents

Allergic Rhinitis

Background

Evaluation

Management