Basics
Description
- Inflammation of the nasal and sinus mucosae, associated with sneezing, swelling, increased mucus production, and nasal obstruction; may be classified as seasonal, perennial, or a combination
- Seasonal: periodic symptoms, involving the same season for at least 2 consecutive years; most often due to pollens (e.g., trees, grass, weeds) and outdoor spores
- Perennial: occurring at least 9 months of the year; may be more difficult to detect because of overlap with other infections; may be due to multiple seasonal allergies or continual exposure to allergens (e.g., dust mites, cockroaches, molds, and animal dander)
- Perennial, with seasonal exacerbations
- The Allergic Rhinitis and Its Impact on Asthma (ARIA) World Health Organization expert panel prefer the classification for allergic rhinitis of intermittent or persistent, with subclassifications of mild, moderate, or severe.
Epidemiology
Prevalence
Most common allergic disease; affecting approximately 40 million Americans; affects 40% of children and 15% " “30% of adolescents ‚
Risk Factors
Genetics
Increased incidence in families with atopic disease. If 1 parent has allergies, each child has approximately a 30% chance of having an allergy; if both parents have allergies, each child has a 70% chance of having an allergy. ‚
General Prevention
- Minimize exposure to dust mites: Consider removing carpets, upholstered furniture, and curtains; washing bedding in hot water frequently, at least every 1 " “2 weeks; use pillow and mattress covers.
- Minimize exposure to animal dander.
- Minimize exposure to all animals; consider using solutions containing tannic acid, which will denature animal allergens; shampoo pets frequently if pets cannot be removed from the household; use air vent filters.
- Minimize exposure to pollens: Keep windows closed, use air-conditioning and avoid leaf raking or lawn mowing.
- Minimize exposure to molds: Keep houseplants out of the bedroom; avoid spending time in the basement, keep humidity at 35 " “50%.
- Early introduction of complementary foods " ”particularly cereals, fish, eggs " ”prior to a year of age was inversely associated with allergic rhinitis.
Etiology
- Indoor allergens: house dust mite, cockroaches, animal dander, cigarette smoke, hair spray, paint, molds
- Pollens: tree pollens in early spring, grass in late spring and early summer, ragweed in late summer and autumn
- Multiple environmental factors
- Changes in air temperature
Commonly Associated Conditions
- Asthma
- Allergic conjunctivitis
- Atopic dermatitis (eczema)
- Urticaria
- Otitis media with effusion
- Sleep, taste, and/or smell disturbance
- Nasal polyps
- Mouth breathing
- Snoring
- Adenoidal hypertrophy and sleep apnea
- Decreased appetite
- Delayed speech
Diagnosis
History
- Typical symptoms: Patient often reports bilateral stuffy nose, sneezing, itching, runny nose, noisy breathing, snoring, cough, halitosis, and repeated throat clearing. Sensation of plugged ears and wheezing may occur.
- Red and itchy eyes
- Symptom occurrence: seasonal, perennial, or episodic
- Exacerbating factors including pollen, animals, cigarette smoke, dust, molds
- Family history of atopic disease such as asthma or atopic dermatitis
- Any related illnesses: Asthma, urticaria, eczema, ear infections, and delayed speech are commonly associated conditions.
Physical Exam
- Allergic shiners
- Dark discoloration beneath the eyes due to obstruction of lymphatic and venous drainage, chronic nasal obstruction, and suborbital edema
- Dennie-Morgan lines
- Creases in the lower eyelid radiating outward from the inner canthus; caused by spasm in the muscles of M ƒ ¼ller around eye due to chronic congestion and stasis of blood
- Allergic salute
- A gesture characterized by rubbing the nose with the palm of the hand upward to decrease itching and temporarily open the nasal passages
- Allergic crease
- Transverse crease near the tip of the nose, secondary to rubbing
- Nasal mucosa may appear pale and/or edematous; mucoid or watery material may be seen in the nasal cavity; check for nasal polyps and septal deviation.
Diagnostic Tests & Interpretation
- Audiometry and tympanometry when indicated
- Sweat test if cystic fibrosis is suspected or if nasal polyps are present
Lab
- Nasal cytology
- Specimen of nasal discharge to check for the presence of eosinophils. Have the patient blow his or her nose into a piece of nonporous paper or collect discharge with a cotton swab and transfer the discharge to a glass slide. >10% eosinophils are considered positive for nasal eosinophilia. Note: Use of intranasal steroids may reduce the number of eosinophils found in nasal discharge.
- Radioallergosorbent tests (RAST)
- In vitro test to measure allergen-specific IgE; expensive; useful in patients who have diffuse atopic dermatitis. The ImmunoCAP system (Pharmacia Diagnostics) is the preferred method for specific IgE testing; uses a single blood sample to identify levels of specific IgE to a number of common respiratory allergens (available as a profile specific to the region of the country where the patient resides), food antigens (food allergy profile), or both (childhood allergy profile)
- Total IgE: elevated in allergic rhinitis; not routinely indicated but may come as part of specific IgE testing; >100 kU/L is considered elevated.
- CBC: may show eosinophilia; not routinely indicated
- Skin testing
- Skin prick test: percutaneous, qualitative test in which antigen concentrate is placed on the skin of the volar surface of the arm or upper back, and a needle is inserted; high negative predictive value; the skin reaction is graded subjectively from 0 to 4.
- Intradermal test: qualitative test in which antigen is introduced intradermally (0.02 mL with a 26 " “30-gauge needle); more sensitive than the prick test and often used if prick test is negative or equivocal; the degree of swelling and erythema is graded from 0 to 4.
- Caution: Skin tests may be difficult to interpret in patients with diffuse eczema and dermatographism.
- Although positive allergen-specific IgE testing or skin prick testing denote sensitization to an allergen, these positive tests must be interpreted in the context of the clinical presentation.
Diagnostic Procedures/Other
Rhinoscopy to assess the nasal turbinates and to look for nasal polyps ‚
Differential Diagnosis
- Infection
- Viral upper respiratory tract infection
- Bacterial sinusitis
- Environmental
- Foreign body
- Temperature
- Odors
- Tumors
- Nasal polyps
- Dermoid cyst
- Nasal glioma
- Congenital
- Cystic fibrosis
- Choanal atresia
- Ciliary motility disorder (e.g., immotile cilia syndrome)
- Septal deviation
- Primary atrophic rhinitis
- Immunologic
- Sarcoidosis
- Granulomatosis with polyangiitis (Wegener granulomatosis)
- Systemic lupus erythematosus
- Sj ƒ ¶gren syndrome
- Allergic
- Nonallergic perennial rhinitis
- Idiopathic (vasomotor) rhinitis
- Drug-induced rhinitis
- Food-induced rhinitis
- Miscellaneous
- Rhinitis medicamentosa
- Rhinitis associated with pregnancy/other hormonal rhinitis
- Hypothyroidism
- Idiopathic neonatal rhinitis
Treatment
Medication
- Improve mucociliary flow.
- Steam inhalation
- Normal saline drops
- Bicarbonate spray
- N-acetylcysteine (orally or inhaled)
- Oral guaifenesin
- Antihistamines: competitively blocking histamine (H1) receptors; suppress itching, ocular symptoms, sneezing, and rhinorrhea; not very effective against nasal congestion
- Intranasal 2nd-generation antihistamine
- Azelastine: age ≥5 years; 137 mcg per spray; 1 spray per nostril twice a day. Safety and effectiveness of this dose have been established for children older than 5 years, but the efficacy has not yet been established in the pediatric population and is extrapolated from adult data.
- 2nd-generation antihistamines: tend not to cross the blood " “brain barrier and therefore do not have CNS side effects such as drowsiness
- Loratadine (Claritin): FDA-approved for children as young as 2 years of age. Dose: ages 2 " “5 years, 5 mg/day PO; ages 6 years or older, 10 mg/day PO
- Desloratadine (Clarinex): FDA-approved for children ≥6 months of age. Dose: 6 " “12 months, 1 mg/day PO; 12 months " “5 years, 1.25 mg/day PO; 6 " “12 years, 2.5 mg/day PO; >12 years, 5 mg/day PO
- Cetirizine HCl (Zyrtec): FDA-approved for children as young as 6 months of age. Dose: age 6 months " “5 years, 2.5 mg = 1/2 tsp/day (1 mg/mL banana " “grape-flavored syrup) PO with maximum dose of 5 mg/day (must be divided into 2.5 mg b.i.d. for children <2 years of age). Age ≥6 years, 5 " “10 mg/day
- Levocetirizine (Xyzal): dose: age 6 months " “5 years: 1.25 mg/day (1/2 tsp = 2.5 mL); ages 6 " “11 years: 2.5 mg/day (half tab or 1 tsp = 5 mL) PO; age ≥12 years: 5 mg/day (1 tab or 2 tsp = 10 mL) PO
- Fexofenadine HCl (Allegra): ages 2 " “11 years: 1 tsp = 5 mL (30 mg/5 mL) or 30-mg tab b.i.d.; age ≥12 years, 60 mg b.i.d. or 180 mg/24 h PO
- 1st-generation antihistamine side effects include drowsiness, performance impairment, and paradoxical excitement; anticholinergic (e.g., dry mouth, tachycardia, urinary retention, and constipation): diphenhydramine (Benadryl) 5 mg/kg/day PO divided q.i.d.
- Intranasal steroids: blunt early-phase reactions and block late-phase reactions; may not be fully effective until several days to 2 weeks after initiation of therapy; must be used regularly and best when administered lying down with the head back
- Beclomethasone (Vancenase, Beconase): for use in children ≥6 years of age
- Flunisolide (Aerobid): for use in children ≥6 years of age
- Fluticasone propionate (Flonase 0.05%): for use in children ≥4 years of age
- Budesonide (Rhinocort): for use in children ≥6 years of age
- Triamcinolone acetonide (Nasacort): for use in children ≥2 years of age
- Mometasone furoate monohydrate (Nasonex): for children ≥2 years of age
- Intranasal antihistamines: azelastine hydrochloride (Astelin; approved for children ≥5 years; 5 " “11 years: 1 spray each nostril b.i.d.; ≥12 years: 2 sprays each nostril b.i.d.) and olopatadine (Patanase; approved for children ≥6 years; 6 " “11 years: 1 spray per nostril b.i.d.; 12 years and older: 2 sprays per nostril b.i.d.) are FDA-approved for use in seasonal allergic rhinitis.
- Topical cromolyn (Nasalcrom): mast cell stabilizer; minimal side effects; does not provide immediate relief (may take 2 " “4 weeks to see clinical effect): for use in children ≥2 years of age
- Oral decongestants: Alpha-1 and -2 agonists (e.g., ephedrine, pseudoephedrine, and phenylephrine) act to cause vasoconstriction, decreased blood supply to the nasal mucosa, and decreased mucosal edema. Cardiovascular and CNS side effects include tremors, agitation, hypertension, insomnia, and headaches.
- Topical decongestants: Sympathomimetics such as short-acting phenylephrine (Neo-Synephrine) and long-acting oxymetazoline (Afrin) may be useful for a few days to open nasal passages to allow for delivery of topical steroids; side effects include drying of the mucosa and burning. Use for more than a few (3 " “5) days may result in rebound vasodilatation and congestion (rhinitis medicamentosa).
- Combined oral decongestants and antihistamines: numerous preparations on the market
- Leukotriene receptor antagonist (montelukast [Singulair]): for use in children ≥6 months of age. Dose for 6 months to 23 months, one packet 4-mg granules; 2 " “5 years, 1 granule packet (4 mg) or 4-mg chewable tab daily; 6 " “14 years, 5-mg chewable tab daily; age ≥15 years, 10-mg tab daily
- Immunotherapy: also referred to as hyposensitization or desensitization; consists of a series of injections with specific allergens, with increasing concentrations of allergens, once or twice weekly; recommended for patients who have not responded to pharmacologic therapy
- Effective and long lasting. After several months to years of treatment, total serum IgE levels decrease, and the intensity of the early-phase response is reduced.
- Side effects include urticaria, bronchospasm, hypotension, and anaphylaxis.
Additional Therapies
General Measures
Avoidance therapy: Identify and eliminate known/suspected allergens. ‚
Surgery/Other Procedures
- Removal of allergic polyps
- Inferior turbinate surgery to reduce the size of the turbinate and relieve obstruction
- Endoscopic sinus surgery to relieve obstruction
Ongoing Care
Follow-up Recommendations
Patient Monitoring
Fever, prolonged or severe headache, dizziness, pain, or purulent discharge should suggest a diagnosis other than allergic rhinitis alone ‚
Prognosis
Generally good: Complete recovery occurs in 5 " “10% of patients. ‚
Complications
- Chronic sinusitis
- Recurrent otitis media
- Hoarseness
- Loss of smell
- Loss of hearing
- High-arched palate and dental malocclusion from chronic mouth breathing
Additional Reading
- Bro … ºek JL, Bousquet J, Baena CE, et al. Allergic rhinitis and its impact on asthma (ARIA) 2010 revision. http://www.whiar.org/docs/ARIAReport_2010.pdf. Accessed September 4, 2013.
- Nwaru ‚ BI, Takkinen ‚ HM, Niemela ‚ O, et al. Timing of infant feeding in relation to childhood asthma and allergic diseases. J Allergy Clin Immunol. 2013;131(1):78 " “86. ‚ [View Abstract]
- Phan ‚ H, Moeller ‚ ML, Nahata ‚ MC. Treatment of allergic rhinitis in infants and children: efficacy and safety of second-generation antihistamines and the leukotriene receptor antagonist montelukast. Drugs. 2009;69(18):2541 " “2576. ‚ [View Abstract]
- Radulovic ‚ S, Calderon ‚ MA, Wilson ‚ D, et al. Sublingual immunotherapy for allergic rhinitis. Cochrane Database Syst Rev. 2010;(12):CD002893. doi:10.1002/14651858.CD002893.pub2. ‚ [View Abstract]
- Sicherer ‚ SH, Wood ‚ RA, American Academy of Pediatrics Section on Allergy and Immunology. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics. 2012;129(1):193 " “197. ‚ [View Abstract]
- Turner ‚ PJ, Kemp ‚ AS. Allergic rhinitis in children. J Paediatr Child Health. 2012;48(4):302 " “310. ‚ [View Abstract]
- Wallace ‚ DV, Dykewicz ‚ MS, Berstein ‚ DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(2)(Suppl):S1 " “S84. ‚ [View Abstract]
Codes
ICD09
- 477.9 Allergic rhinitis, cause unspecified
- 477.0 Allergic rhinitis due to pollen
- 477.8 Allergic rhinitis due to other allergen
- 477.2 Allergic rhinitis due to animal (cat) (dog) hair and dander
- 477.1 Allergic rhinitis due to food
ICD10
- J30.9 Allergic rhinitis, unspecified
- J30.1 Allergic rhinitis due to pollen
- J30.89 Other allergic rhinitis
- J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander
- J30.5 Allergic rhinitis due to food
- J30.2 Other seasonal allergic rhinitis
SNOMED
- 61582004 Allergic rhinitis (disorder)
- 367498001 Seasonal allergic rhinitis (disorder)
- 446096008 perennial allergic rhinitis (disorder)
- 232353008 Perennial allergic rhinitis with seasonal variation (disorder)
- 91925003 Allergic rhinitis due to animals
- 441978001 Allergic rhinitis due to food
- 21719001 allergic rhinitis due to pollen (disorder)
FAQ
- Q: How does one minimize exposure to dust mites?
- A: Keep household temperature low; maintain humidity at ¢ ˆ ¼40 " “50%; wash linens weekly at hot temperatures; use a microfilter when vacuuming; place mattress and box spring in tightly woven casing; use air-conditioning; use high-efficiency particulate air filter units.
- Q: How often are nasal polyps associated with cystic fibrosis?
- A: In up to 40% of children, nasal polyps are associated with cystic fibrosis. <0.5% of children with asthma and rhinitis have nasal polyps.
- Q: When used on a daily basis, are intranasal steroids safe?
- A: Yes. It is generally accepted that inhaled steroids are safe. Growth suppression has been reported in children using certain intranasal steroids; however, this effect does not appear to be an effect of all intranasal steroids. Importantly, one should use the lowest effective dose of intranasal steroids when treating allergic rhinitis.