Allergic Rhinitis

Allergic rhinitis, often referred to as hay fever, is an allergic reaction that occurs when the immune system overreacts to particles inhaled into the nose. It’s a common condition affecting a significant portion of the population.

Causes

  • Environmental Allergens: Such as pollen from trees, grasses, and weeds, especially during specific seasons.
  • Perennial Allergens: Such as dust mites, pet dander, cockroaches, and mold, which can cause year-round symptoms.
  • Irritants: Tobacco smoke, pollution, and strong odors can exacerbate symptoms.

Diagnosis

  • Clinical History: Includes onset, duration, and seasonality of symptoms, exposure to known allergens, and family history of allergies.
  • Symptoms: Sneezing, nasal congestion, runny nose, itchy nose, and postnasal drip. Associated symptoms can include itchy, red, or watery eyes, and itchy throat or ears.
  • Physical Examination: Examination of the nasal passages for swelling, pallor, or bluish discoloration of the nasal mucosa. Checking for signs of conjunctivitis or eczema, which can accompany allergic rhinitis.
  • Allergy Testing: Skin prick tests or specific IgE blood tests to identify specific allergen sensitivities.

Differential Diagnosis

  • Non-Allergic Rhinitis: Symptoms similar to allergic rhinitis but without an allergic trigger.
  • Infectious Rhinitis (Common Cold): Typically presents with sore throat, fever, and malaise.
  • Sinusitis: Inflammation of the sinuses, often with facial pain and purulent nasal discharge.
  • Nasal Polyps: Can cause nasal obstruction, loss of smell, and chronic congestion.
  • Medication-Induced Rhinitis: Especially due to prolonged use of topical nasal decongestants (Rhinitis medicimentosa)

Management

  • Avoidance of Allergens: Key component where possible. For instance, using air purifiers for dust mites or keeping pets out of the bedroom.
  • Pharmacotherapy:
    • Nasal Saline Irrigation (Fess) 
    • Intranasal Corticosteroids: First-line treatment for moderate to severe symptoms.
      • Fluticasone furoate (Avamys) i-ii BN OD (> 2 years)
      • Mometasone (Nasonex) i-ii BN OD (> 3 years)
      • Beclomethasone (Beconase) 1-ii BN BD (> 6 years)
      • Budesonide (Rhinocort) i-ii BN BD (> 6 years)
    • Antihistamines:
      • Oral (easier)
        • Loratidine 5-10mg oral OD
      • Intranasal
        • Azelastine (Azep) i BN BD (> 5 years)
        • Azelastine+Fluticasone (Dymista) i BN BD
    • Decongestants: Short-term relief of nasal congestion but should be used cautiously:
      • Oxymetazoline (Drixine) ii BN BD (> 6 years)
      • If used for > 3 days rebound congestion (Rhinitis Medicamentosa)
    • Mast Cell Stabilizers: Like Ipratropium can prevent the release of histamine and other chemicals.
      • Ipratropium ii BN TDS PRN
    • Leukotriene Receptor Antagonists: Such as montelukast, particularly in patients with concomitant asthma.
      • Montelucast 5- 10mg oral OD
  • Immunotherapy: Allergen immunotherapy can be considered for patients with persistent symptoms despite pharmacotherapy, usually administered under the guidance of an allergy specialist.
  • Patient Education: On the nature of the condition, the role of allergen avoidance, and the proper use of medications.

Referral

  • Referral to an Allergist: For patients with severe symptoms, those who wish to pursue allergen immunotherapy, or if there’s uncertainty in the diagnosis.
  • Evaluation for Comorbid Conditions: Such as asthma, sinusitis, or nasal polyps, particularly if symptoms are refractory to standard treatment.

Conclusion

Allergic rhinitis is a common and often manageable condition with a combination of allergen avoidance strategies, pharmacotherapy, and patient education. Understanding the specific triggers through appropriate diagnostic evaluation is essential for targeted management. In cases of severe or refractory symptoms, referral to an allergy specialist can provide further treatment options like immunotherapy.