Allergic rhinitis

1. Dr James
Thornton
Allergic Rhinitis
geekymedics.com/allergic-rhinitis/
Introduction
Allergic rhinitis is inflammation of the epithelial lining of the nose.
It is an extremely common condition seen regularly by both general practitioners and in
ear nose and throat (ENT) clinics. It is estimated that allergic rhinitis affects 1 in 5
people in the United Kingdom.
Aetiology
Allergic rhinitis typically affects the nasal passages but can affect the entire upper
respiratory tract. Symptoms are most often due to an IgE-associated response to
common indoor and outdoor allergens. Examples of allergens include pollen, dust
mites, mould, cigarette smoke and animal skin flakes.
Additionally, prolonged occupational or recreational exposure to proteins not
commonly associated with an allergic response can occur. For example, woodworkers
becoming sensitised to wood dust and food workers sensitised to grain dust.
Allergic rhinitis is traditionally divided into seasonal and perennial forms. The more
modern classifications of allergic rhinitis take into account the spectrum of severity;
ranging from mild and intermittent up to persistent and severe; with the associated
impact on sleep, school/work performance and daily activities.
Risk factors
There may be a personal or family history of atopy often as a triad of asthma, eczema
and allergic rhinitis.
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2. Clinical features
History
Typical symptoms of allergic rhinitis include:
Nasal symptoms: sneezing, itching, discharge (rhinorrhoea), hyposmia (reduced
sense of smell) and congestion.
Eye symptoms: itching, watering, redness.
Additional symptoms: postnasal drip, coughing, itching of palate or ears.
Chronic nasal congestion: snoring, mouth breathing, halitosis.
Bilateral symptoms within minutes of allergen exposure.
Other important areas to cover in the history include:
Type, frequency and persistence of symptoms.
Location (indoors or outdoors).
Severity and impact on quality of life (including sleep, concentration, impact on
school or work).
Housing conditions, pets and occupation: to identify possible causative triggers
and allergens.
Occupational history should include nature of the job, duration of employment
before symptoms developed, agents exposed to at work, any improvement in
symptoms when away from work.
Associated atopic symptoms, asthma/wheeze, eczema or family history of such.
Asthma and allergic rhinitis often co-exist. Good control of allergic rhinitis can
have an impact on asthma symptoms.
Previous treatments tried and their effectiveness.
Clinical examination
In cases of suspected allergic rhinitis, a nasal examination should be performed.
Typical clinical findings in allergic rhinitis are shown below.
External/general
Nasal intonation of the voice
“Allergic shiners” – darkened eye shadows under lower eyelids due to chronic
congestion
Erythematous conjunctiva with watering eyes may be evident
Internal nasal examination
Nasal mucosa swelling with greyish discolouration
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3. Check for inflammatory nasal polyps (soft yellow swellings between the nasal
septum and turbinates), hypertrophic nasal turbinates (soft pink swelling arising
from lateral nasal wall), malignant growths (normally unilateral and suggested by
hard/dark appearance, irregular surface and/or ulceration) or foreign bodies
Purulent nasal discharge is more suggestive of infective rhinitis or sinusitis
Differential diagnoses
The largest discrete subsection to consider is that of non-allergic rhinitis. Table 1
gives an overview of the subtypes of non-allergic rhinitis.
Table 1. An overview of the causes of non-allergic rhinitis.
Subtype Features
Idiopathic This is a non-IgE mediated pathway.
Causes include temperature or humidity changes,
exposure to smoke or strong odours and following
exercise.
Occupational/chemical
exposure
For example, work generating sawdust, metal particles or
chemical spraying.
Drug-induced Alpha-blockers, ACE inhibitors, beta-blockers, NSAIDs,
chlorpromazine, cocaine may all cause or aggravate
rhinitis symptoms.
Non-allergic rhinitis
with eosinophilia
syndrome (NARES)
Defined as a syndrome of nasal hyperreactivity over more
than 3 months in the absence of any atopic factor and
eosinophilia of nasal secretions 20% greater than
leukocytes.
Other Hormonal (e.g. pregnancy)
Food-induced (e.g. spicy foods)
Age-related
Stress or emotion induced
In addition, there are some further causes of rhinitis listed in the table below.
Table 2. An overview of alternative causes of rhinitis
Differential Features
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4. Atrophic
rhinitis
Can be primary (caused by rare infectious diseases, classically
Klebsiella Ozanae) or secondary (e.g. following
chemoradiotherapy or surgery).
Infective
rhinitis or
sinusitis
Features of an associated upper respiratory tract infection (URTI);
cough, fever and/or lymphadenopathy.
If nasal discharge is clear, infection is less likely.
Rhinitis
medicamentosa
Rebound nasal congestion may occur when stopping prolonged
intranasal decongestants.
Systemic Primary defects in mucus production (e.g. cystic fibrosis)
Primary ciliary dyskinesia (Kartagener Syndrome)
Granulomatous disease (e.g. granulomatosis with polyangiitis or
sarcoidosis).
Structural Deviated nasal septum
Nasal polyps
Hypertrophic turbinates
Adenoidal hypertrophy
Foreign body
Malignancy Sinonasal tumours should be excluded if there are unilateral
symptoms, bloody nasal discharge, nasal pain, anosmia or visual
disturbance.
Investigations
If the classic features of allergic rhinitis are present then the diagnosis is usually
made clinically without the need for investigations.
Investigations to consider may include:
Trial of antihistamines and/or intranasal corticosteroid: can be performed easily
in primary care.
Allergen skin-prick testing: if the allergen not easily identified from the history.
In vitro specific IgE determination: some specialists may use this in identifying
symptom trigger.
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5. Testing of the sense of smell and nasal airflow (e.g. rhinomanometry) are rarely used
outside of research settings.
Management
Conservative
Conservative measures depend on the underlying aetiology of the patient’s allergic
rhinitis.
All patients should be offered information regarding the condition. For example,
Allergy UK provides an online factsheet for patients.
Additionally, some patients may find nasal irrigation with saline useful. Devices for
this purpose can be bought over the counter.
Table 3. Conservative management strategies for allergic rhinitis.
Allergen Management suggestions
Grass Avoid grassy open spaces, particularly in the early morning, evening and
when the pollen count is high (patients can check pollen counts online).
Shower after high pollen exposure.
Avoid drying clothes outside when the pollen count is high.
Wear eye protection whenever possible.
Dust
mite
Use synthetic pillows and acrylic duvets and avoid soft toys.
Wash bedding and soft toys at high temperature at least once a week.
Choose wooden or hard floors where possible. Fit wipe-clean blinds
instead of curtains.
Medical
Mild disease
1 line: oral antihistamine (e.g. loratadine or cetirizine). Less sedating
antihistamines are available for patients who are significantly affected.
2 line: intranasal corticosteroids (see moderate/severe disease section)
Adjuvant treatment: intranasal antihistamine (e.g. azelastine). Intranasal
preparations have been shown to have a faster onset of action and are more
effective than oral forms.
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6. Moderate or severe disease
Intranasal corticosteroids can be considered for moderate or severe allergic
rhinitis. Options include beclomethasone (e.g. Beconase), mometasone (e.g. Nasonex)
and fluticasone (e.g Flixonase, Avamys). Advise patients that the maximum effect can
occur after 2 weeks of use. Patients with seasonal rhinitis should commence treatment
before symptoms start.
Intranasal corticosteroids are usually administered as a nasal spray, though drops are
also available. The dose should be monitored in children to avoid affecting growth.
A recent addition to the market is a combined topical corticosteroid and topical
antihistamine spray (Dymista).
Other treatments for more severe cases include systemic corticosteroids (intra-
muscular injection or a short course of oral steroids) or immune therapy (a course of
subcutaneous or sublingual treatment). Leukotriene receptor antagonists (e.g.
montelukast) are considered in patients with concomitant asthma.
When to refer to ENT
A 2-week wait (urgent) referral to ENT should be made if there are red flag
symptoms suggestive of malignancy. These include unilateral symptoms of blood-
stained discharge, nasal pain or recurrent epistaxis.
Routine referral should be considered for patients with persistent symptoms despite
optimal management in primary care or if the diagnosis uncertain.
Surgery is not a treatment for allergy but is sometimes used (e.g. septoplasty, turbinate
reduction) to improve the administration of topical therapies.
Complications
Chronic poorly controlled allergic rhinitis leads to chronic inflammation of the nasal
mucosa and associated obstructive features and complications. These can include an
increased predisposition to acute or chronic sinusitis, otitis media (due to eustachian
tube occlusion), obstructive sleep apnoea and upper respiratory tract infections.
Key points
Allergic rhinitis is a common condition that affects up to 1 in 5 people in the UK.
The classical features are sneezing, nasal discharge, itching and congestion.
Allergic rhinitis is part of the triad of atopy (eczema, asthma and allergic
rhinitis).
Good control of allergic rhinitis is important in concomitant asthma symptom
control.
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7. Conservative measures include allergen avoidance and nasal rinsing.
Medical management includes oral or intranasal antihistamines and topical
corticosteroids.
Urgent ENT referral if red flag symptoms of unilateral bleeding, discharge and
pain.
Consider routine ENT referral if persistent symptoms despite best medical
therapy or unclear diagnosis.
Editor
Mr Stephen Broomfield
Consultant ENT Surgeon, Bristol Royal Infirmary
Editor
Dr Chris Jefferies
References
1. NHS Patient Info. Allergic Rhinitis. Published in April 2019. Available from:
[LINK].
2. BMJ Best Practice. Allergic Rhinitis. Updated April 2020. Available from: [LINK].
3. T. Clark. BSACI guideline for the diagnosis and management of allergic and non-
allergic rhinitis. Revised edition published 2017
4. NICE CKS. Allergic Rhinitis. Published September 2018. Available from: [LINK].
5. J. Schunemann. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines.
Revised edition published 2016
6. Bunnag C, Jareoncharsri P, Tansuriyawong P, Bhothisuwan W, Chantarakul N.
Characteristics of atrophic rhinitis in Thai patients at the Siriraj
Hospital. Rhinology;37(3):125–130. Published 1999
7. DP Skoner. Complications of Allergic Rhinitis. Journal of Allergy and Clinical
Immunology. Published June 2000. Available from: [LINK].
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