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Chapter 65: Allergic Rhinitis

Hanna Phan; Michael Daines

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Describe the basic pathophysiology of allergic rhinitis (AR).

  2. Define mild versus moderate–severe AR, persistent versus episodic, and differentiate between seasonal, perennial, and episodic AR.

  3. Differentiate the categories of pharmacotherapy choices for treatment of AR based on mechanism, efficacy on symptom type (eg, ocular, nasal congestion), and side effect profile.

  4. Identify situations in which a referral to an allergy specialist is needed.

  5. Describe an approach for treatment and monitoring for treatment of mild and moderate–severe AR based on patient-specific factors.

  6. Identify the differences in approach to the treatment of AR for children, pregnant women, and the elderly compared with the routine approach in adults.

INTRODUCTION

Rhinitis is inflammation of the lining of the nose and contiguous parts of the upper respiratory tract. Allergy is only one of numerous causes of rhinitis. Signs and symptoms of allergic rhinitis are noted in Table 65–1. Some patients suffer concurrently from both allergic rhinitis (AR) and one or more types of nonallergic rhinitis (NAR). This is sometimes called mixed rhinitis (MR). Because ocular symptoms (eg, itching and/or redness of eyes, tearing) frequently occur in association with AR, some sources use the term allergic rhinoconjunctivitis. This acknowledges involvement of the bulbar and palpebral conjunctivae in the allergic process.1-4

Table 65–1Clinical Presentation and Diagnosis of Allergic Rhinitis1-4
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Table 65–1 Clinical Presentation and Diagnosis of Allergic Rhinitis1-4

Typical Symptoms

  • Rhinorrhea (usually clear and bilateral; primarily anterior but may be posterior [postnasal drip])

  • Sneezing

  • Itching (mostly nasal, but also palate, throat, eyes, ears)

  • Nasal congestion (not in all patients, but when present, usually the most troublesome symptom)

Other Symptoms

  • Ocular manifestations (itch, redness, tearing, chemosis, periorbital edema)

  • Sleep disturbances often with fatigue, asthenia, malaise, and irritability

  • Presenteeism (impaired performance at work or school)

  • Absenteeism from work or school

  • Quality-of-life impairment (including social function)

  • Headache, mild facial or ear pain or fullness

  • Cough (especially in those with concurrent asthma)

  • Children (especially): snorting, sniffling, clearing the throat, learning or attention problems, poor appetite

Signs (Especially Common in Children)

  • Pale, boggy nasal mucosa

  • Rubbing the nose upward (allergic salute; may create horizontal crease just above tip of nose)

  • Rubbing/scratching of eyes

  • Mouth breathing

  • Dark circles under the eyes (allergic shiners)

  • Dennie-Morgan lines or folds under the eyes

Diagnosis

  • Typical symptoms, confirmatory signs, especially in association with exposure to allergen triggers

  • Other diagnostic testing usually optional but may be necessary to rule out nonallergic causes or if immunotherapy is considered (appropriate physical examination, specific IgE antibody testing by either skin testing or in vitro serum testing, other specialized testing)

  • Several sources particularly good for differential diagnosis of nonallergic rhinitis3,13,15

  • Vasomotor rhinitis—sneezing and itch less common than AR; anosmia more common

  • Unilateral symptoms—refer for possible obstruction, anatomic abnormality, tumor, cerebrospinal ...

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