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Allergic Rhinitis

Essentials

  • The connection and interrelatedness between rhinitis and asthma must be borne in mind, and whenever possible the investigations and treatment should include both conditions.
  • Instead of trying to avoid allergens, the patient's tolerance to allergens should be enhanced in different ways. The avoidance of allergens is needed when the symptoms are severe, but as soon as the situation has calmed down, methods that strengthen tolerance should preferably be applied.
  • Investigations performed by an ENT specialist are required if the symptoms are severe and unresponsive to treatment, if allergen-specific immunotherapy (desensitisation) is considered or if there is a suspicion of occupational rhinitis.

Signs and symptoms

  • See table T1

Signs and symptoms in the different forms of hypersensitivity rhinitis

Allergic rhinitisNon-allergic rhinitis
EosinophilicNon-eosinophilic (vasomotor)
Genetic predispositionYes (tendency for atopy)NoNo
Age at onsetChildhoodMiddle-age (30-50 yrs)Middle-age (often > 40 yrs)
Occurrence of symptomsSeasonal, may also be perennialPerennialPerennial
AsthmaIn about 20%In 30-40%Rare
PolypsOccasionallyOftenRarely
Prick/RAST tests positiveYesNoNo
Secretory eosinophiliaOftenIn all patients at some stage (diagnostic criterion)No

Epidemiology

  • Atopic IgE-mediated allergic rhinitis affects about 25-30% of the adult population in Western Europe. In the majority of cases rhinitis is caused by pollen allergy (deciduous trees, grasses, mugwort). Other common causes of allergic rhinitis include animal and cereal allergens and other organic dusts, often from occupational exposure. Additionally, about 10% of adults have chronic non-allergic hypersensitivity rhinitis.

Investigations and findings

  • Carefully compiled patient history
    • Previous history of atopy
    • The character of symptoms (seasonal or all year round; intermittent or persistent according to ARIA [Allergic Rhinitis and its Impact on Asthma] classificationhttp://www.euforea.eu/about-us/aria.html, picture 1)
    • Symptoms (clear nasal secretions, stuffy and itching nose, rhinorrhoea, sneezing)
      • About 70% of patients with allergic rhinitis have concurrent conjunctival symptoms in the eyes (redness, tearing, itching).
    • Associated diseases (sinusitis, otitis media, asthma)
    • Exposure data (particularly if an occupational disease is suspected)
  • Rhinoscopy, preferably using a headlight and topical nasal decongestant (a complete ENT examination is indicated during the first visit), if the patient complains of nasal congestion.
    • The aim is to identify nasal polyps Nasal Polyps.
    • Livid pale grey or bluish mucous membranes (suggestive of an allergic reaction, but other types of findings do not exclude allergy)
    • Secretions may vary from clear watery to mucous.
  • An ultrasound examination may be performed to check the presence of secretions in the maxillary sinuses if the symptoms suggest acute bacterial rhinosinusitis.
  • An x-ray of the paranasal sinuses is helpful in the evaluation of chronic sinusitis, particularly if the symptoms have persisted for a long time (months to years).
    • In children, x-ray studies should only be carried out after careful consideration within specialized health care and preferably by using cone-beam CT of the paranasal sinuses.
  • Serum IgE studies and/or skin prick tests are indicated for the planning of treatment, for consideration of allergen-specific immunotherapy (desensitisation) and for diagnosing possible occupational rhinitis Investigation of Atopy.

Further investigations

  • Referral to an ENT specialist is warranted when
    • the patient has severe, treatment-resistant rhinitis
    • desensitisation therapy is considered Allergen Immunotherapy
    • occupational rhinitis is suspected.

ARIA guidelines

  • ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines http://www.euforea.eu/about-us/aria.html, which have been drafted by an expert panel together in collaboration with the WHO, are research and treatment guidelines for general practitioners and specialists. The emphasis is on the concept "one airway, one disease". The connection and inter-relatedness of rhinitis and asthma must be borne in mind and whenever possible the investigations and treatment should include both conditions.

Treatment

Pharmacotherapy in different types of rhinitis

Seasonal allergic rhinitis

Perennial allergic rhinitis

NARES (non-allergic rhinitis with eosinophilia syndrome)

  • Pharmacotherapy consists of the same medication as that used in allergic rhinitis.

Non-allergic hypersensitivity rhinitis, vasomotor rhinitis

    References

    • Brozek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 2010;126(3):466-76. [PubMed]http://www.euforea.eu/assets/pdfs/aria/2010-ARIA-Report.pdf
    • VSeidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152(1 Suppl):S1-43. [PubMed]