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Allergic Rhinitis

Allergic rhinitis is an inflammation of the nasal membranes that presents with any of nasal congestion, itching, sneezing and rhinorrhea or a combination of any or all of them.


Presentation

  • Symptoms associated with this condition include pruritus of the nose or palate, rhinorrhea, sneezing, postnasal drip, nasal congestion, anosmia, headache, tearing, eye swelling, red eyes, earache, fatigue, drowsiness and a general feeling of malaise.
  • At presentation, history taking should also involve questions to determine trigger factors, familial history, and comorbid conditions.
  • Physical examination will reveal allergic shiners and nasal crease. The nasal turbinates may be enlarged and there may be erythema of the mucosa. The ears, eyes and neck as well as skin and lungs should be examined.
Hemophilia A
  • KEYWORDS: allergic rhinitis; mild hemophilia; nasal hemophilic pseudotumor[ncbi.nlm.nih.gov]
Fatigue
  • These symptoms can lead to poor sleep, which can result in significant daytime sleepiness and fatigue. Allergic rhinitis (allergies) may occur year-round or seasonally.[sleepfoundation.org]
  • It may lead to fatigue, drowsiness, and malaise thus causing impairment of the quality of life.[icd9data.com]
  • Allergic rhinitis may result in sleep disturbance, fatigue, depression of mood-cognitive function and quality of life impairment.[ncbi.nlm.nih.gov]
  • Fibromyalgia, chronic fatigue syndrome, migraine and chronic cough, syndromes, which are commonly related to neurokinin substance P (SP) in the literature, also show strong female predominance.[ncbi.nlm.nih.gov]
  • Other symptoms are headache, earache, red eyes, itchy eyes, drowsiness, fatigue and a general feeling of unwell. Diagnosis: This is done with the help of certain tests to check what causes the allergic reaction.[symptoma.com]
Lymphadenopathy
  • Abstract It is extremely uncommon to find a patient with rheumatoid arthritis with pulmonary and cardiac manifestations together with co-existent intrathoracic lymphadenopathy.[ncbi.nlm.nih.gov]
Multiple Congenital Anomalies
  • Abstract Klippel-Feil syndrome KFS, a triad of short neck, limitation of neck movement and low posterior hairline, is characterized by presence of congenitally fused cervical vertebrae and is often associated with multiple congenital anomalies.[ncbi.nlm.nih.gov]
Pseudotumor
  • Pseudotumor should always be considered in hemophiliac patients, even in those with only mild deficiency of coagulation factors. 2017 Japan Pediatric Society. KEYWORDS: allergic rhinitis; mild hemophilia; nasal hemophilic pseudotumor[ncbi.nlm.nih.gov]
Sneezing
  • SC can be as effective as MF on both sneezing and nasal rubbing on regular use over three weeks.[ncbi.nlm.nih.gov]
  • Symptoms include sneezing, nasal congestion, rhinorrhea, and itching. It may lead to fatigue, drowsiness, and malaise thus causing impairment of the quality of life.[icd9data.com]
  • BACKGROUND: Allergic rhinitis is a nasal mucosa inflammatory disorder that is induced by exposure to an allergen which results in four major symptoms, including anterior or posterior rhinorrhea, sneezing, nasal itching and nasal congestion.[ncbi.nlm.nih.gov]
  • CHM may also decrease the recurrence and level of immunoglobulin E, and improve symptoms such as sneezing, running nose, and nasal congestion, compared with controls.[ncbi.nlm.nih.gov]
  • We observed that this population of cells inhibited sneezing, nose rubbing, and changes in the pathology of the nasal mucosa.[ncbi.nlm.nih.gov]
Nasal Congestion
  • BACKGROUND: Allergic rhinitis is a nasal mucosa inflammatory disorder that is induced by exposure to an allergen which results in four major symptoms, including anterior or posterior rhinorrhea, sneezing, nasal itching and nasal congestion.[ncbi.nlm.nih.gov]
  • Symptoms include sneezing, nasal congestion, rhinorrhea, and itching. It may lead to fatigue, drowsiness, and malaise thus causing impairment of the quality of life.[icd9data.com]
  • CHM may also decrease the recurrence and level of immunoglobulin E, and improve symptoms such as sneezing, running nose, and nasal congestion, compared with controls.[ncbi.nlm.nih.gov]
  • At the 8-mo follow-up visit, her nasal congestion was reported to be entirely gone.[ncbi.nlm.nih.gov]
  • The primary objective was superiority to placebo by the change of the total nasal symptom score (sneezing, rhinorrhea, and nasal congestion) in Week 2. Levocetirizine was a reference drug and not a comparator in this study.[ncbi.nlm.nih.gov]
Rhinorrhea
  • Abstract Unilateral cerebrospinal fluid (CSF) rhinorrhea as the only manifestation of the primary empty sella syndrome is a rare event.[ncbi.nlm.nih.gov]
  • Symptoms include sneezing, nasal congestion, rhinorrhea, and itching. It may lead to fatigue, drowsiness, and malaise thus causing impairment of the quality of life.[icd9data.com]
  • A high index of suspicion for this condition should be maintained in all patients who present with profuse and often unilateral rhinorrhea.[ncbi.nlm.nih.gov]
  • Here, we present a case of a 50-year-old woman with 20 years of rhinorrhea before a diagnosis of cerebrospinal fluid leak and a life-threatening complication occurred.[ncbi.nlm.nih.gov]
  • BACKGROUND: Allergic rhinitis is a nasal mucosa inflammatory disorder that is induced by exposure to an allergen which results in four major symptoms, including anterior or posterior rhinorrhea, sneezing, nasal itching and nasal congestion.[ncbi.nlm.nih.gov]
Common Cold
  • Blocked sinuses can be caused by the common cold, hay fever or nasal polyps (small lumps inside the nose).[who.int]
  • An inflammation of the mucous membrane lining of the nose, usually associated with a nasal discharge; it may be caused by a viral infection, as in the common cold; or by allergic reaction, as in hay fever; also called coryza.[curlie.org]
  • Some cases are the result of: an infection, such as the common cold oversensitive blood vessels in the nose overuse of nasal decongestants This type of rhinitis is known as non-allergic rhinitis .[nhs.uk]
  • Rhinovirus, the cause of the common cold, causes runny noses and triggers asthma attacks in the fall and spring.[web.archive.org]
  • Symptoms and Complications Most people with allergic rhinitis know they have it, although it can sometimes be confused with the common cold. Symptoms include runny nose; sneezing; itchy nose, mouth, throat, or eyes; and congestion.[medbroadcast.com]
Anosmia
  • Symptoms associated with this condition include pruritus of the nose or palate, rhinorrhea, sneezing, postnasal drip, nasal congestion, anosmia, headache, tearing, eye swelling, red eyes, earache, fatigue, drowsiness and a general feeling of malaise.[symptoma.com]
  • Signs and Symptoms History Signs and symptoms of allergic rhinitis include the following: Sneezing Itching: Nose, eyes, ears, palate Rhinorrhea Postnasal drip Congestion Anosmia Headache Earache Tearing Red eyes Eye swelling Fatigue Drowsiness Malaise[emedicine.com]
Regurgitation
  • We report the case of a 40-year-old female with rheumatoid arthritis with rheumatoid lung disease with severe aortic regurgitation, congestive heart failure, bronchial asthma and allergic rhinitis.[ncbi.nlm.nih.gov]
Mouth Breathing
  • New York, American College of Allergy, Asthma and Immunology, 1990 Evidence of allergies such as eczema Mouth breathing Skin testing: pretest probability of allergic rhinitis exceeds treatment threshold for most patients, so treatment without diagnostic[pedclerk.bsd.uchicago.edu]
  • Look for signs suggestive of chronic nasal congestion - mouth breathing, cough, halitosis. Examine eyes for signs of conjunctivitis. Rule out other associated conditions.[patient.info]
  • breathing; cobblestoning in the posterior pharynx secondary to chronic nasal congestion and postnasal drainage Testing No laboratory studies are needed in allergic rhinitis if the patient has a straightforward history.[emedicine.medscape.com]
Halitosis
  • Look for signs suggestive of chronic nasal congestion - mouth breathing, cough, halitosis. Examine eyes for signs of conjunctivitis. Rule out other associated conditions.[patient.info]
Angioedema
  • We have observed an increased frequency of sensitivity to aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), manifested as urticaria or angioedema, in patients with this condition.[ncbi.nlm.nih.gov]
Limitation of Neck Movement
  • Abstract Klippel-Feil syndrome KFS, a triad of short neck, limitation of neck movement and low posterior hairline, is characterized by presence of congenitally fused cervical vertebrae and is often associated with multiple congenital anomalies.[ncbi.nlm.nih.gov]
Ear Fullness
  • Adverse effects of nasal saline irrigation are thought to be rare and generally mild but may include ear fullness, stinging of the nasal mucosa and epistaxis (nosebleed) ( Khianey 2012 ).[doi.org]
Red Eye
  • Other symptoms are headache, earache, red eyes, itchy eyes, drowsiness, fatigue and a general feeling of unwell. Diagnosis: This is done with the help of certain tests to check what causes the allergic reaction.[symptoma.com]
  • Itchy eyes/ throat Sneezing, blocked/runny nose Watering, red eyes (allergic conjunctivitis) Headaches, blocked sinuses Shortness of breath Tiredness The sensation of mucus running down the back of the throat, which can also be a symptom, is called ‘post-nasal[allergyuk.org]
  • Signs and Symptoms History Signs and symptoms of allergic rhinitis include the following: Sneezing Itching: Nose, eyes, ears, palate Rhinorrhea Postnasal drip Congestion Anosmia Headache Earache Tearing Red eyes Eye swelling Fatigue Drowsiness Malaise[emedicine.com]
  • One study recorded different symptoms (nasal discharge, nasal blockage, eye redness, eye itching) ( Garavello 2005 ). Due to the differences in the scales used, we used a standardised mean difference (SMD) in the analysis.[doi.org]
Excessive Tearing
  • tear production; Dennie-Morgan lines (prominent creases below the inferior eyelid); and dark circles around the eyes (“allergic shiners”), which are related to vasodilation or nasal congestion Oropharynx: "Cobblestoning," that is, streaks of lymphoid[emedicine.com]
Short Neck
  • Abstract Klippel-Feil syndrome KFS, a triad of short neck, limitation of neck movement and low posterior hairline, is characterized by presence of congenitally fused cervical vertebrae and is often associated with multiple congenital anomalies.[ncbi.nlm.nih.gov]
Insomnia
  • Except for cromolyn sodium, which is one of the more expensive treatments on the market, most of these drugs display adverse effects such as dizziness, drowsiness, insomnia, nervousness, and gastro-intestinal disorders.[acupuncture.com]
  • Side effects may include nervousness, racing heart, elevated blood pressure, and insomnia. Men with BPH may have difficulty urinating.[health.harvard.edu]
  • Oral decongestants Pseudoephedrine C 2 years (usually not started until 4 years) Vasoconstriction; onset of action is 15 to 30 minutes Headache, elevated blood pressure and intraocular pressure, tremor, urinary retention, dizziness, tachycardia, and insomnia[aafp.org]
  • […] nonprescription decongestants such as pseudoephedrine and phenylephrine in combination with antihistamines. 1 These agents are indicated for temporary relief of nasal and eustachian tube congestion as well as cough associated with postnasal drip. 1 Insomnia[pharmacytimes.com]
Papilledema
  • An eye fundus examination found papilledema suggesting the diagnosis of idiopathic intracranial hypertension. We performed a ventriculoperitoneal shunt without repair of the osteodural defect.[ncbi.nlm.nih.gov]

Workup

  • An allergy skin test should be done to check for the immediate hypersensitivity reaction to specific allergens. A limited number of allergens should be used. The total serum IgE could be increased as well as the total blood eosinophil count.
  • Imaging studies like plain radiograph will help to exclude structural abnormalities as well as detect comorbid conditions. CT scan of the sinuses can help in evaluation sinusitis, whether acute or chronic. MRI is useful for checking the soft tissues for features of malignancy.
  • A nasal smear could also be done and may show eosinophilia [7].

Treatment

The treatment of allergic rhinitis is three pronged.

  • The first is environmental control and avoiding allergens which can be achieved by reducing outdoor exposure, regular washing of bed linens, and avoiding animals [8]. 
  • Second is medications and they include antihistamines, leukotriene receptor antagonists, nasal corticosteroids, and decongestant.
  • The third is immunotherapy which is considered in severe diseases or when there is a poor response to other management options [9].

Prognosis

The long term prognosis of allergic rhinitis, if it occurs alone, is good if it has developed early in childhood as symptoms tend to diminish as one gets older. When people with allergic rhinitis have other coexisting disorders, e.g. asthma, the morbidity is increased and mortality is seen in some cases. Although the condition is not considered severe, it causes enough discomfort to interfere with normal daily function.

Etiology

The pollen responsible for causing haying fever varies from region to region and individual to individual. It is mostly caused by the pollens of wind pollinated plants and examples of these plants include pine, alder, birch, hazel, willow, poplar, plane, lime and olive. It could also result from exposure to grass pollens from grasses like timothy and ryegrass. Weeds that may induce an allergic reaction are plantain, ragweed and mugwort [2]. Allergic rhinitis can also be caused by spores of outdoor molds like apsergillus and penicillin and by house dust mites, furry household pets, cockroaches and rodents [3].

Some people develop a reaction when they are exposed to certain fragrances, especially ones containing Balsam of Peru.

Epidemiology

There is a cumulative prevalence rate of 20% in the United States with as much as 40 million people suffering from this disease. In the international community, the prevalence varies among countries, largely due to their different geographies and availability and potency of allergens.

Morbidity and mortality from allergic rhinitis on its own is insignificant. The condition however occurs concurrently with other conditions like asthma and otitis media which may cause significant morbidity and even mortality.

Most cases develop by age 20 years but it may develop far earlier. In children, it affects more males than females but the ratio evens out in adulthood. It affects people of all races and has no predilection for a particular race [4].

Sex distribution
Age distribution

Pathophysiology

  • It primarily involves inflammation of the mucous membrane of the nose. Other organs may be affected in certain individuals like the eye, ear and pharynx. Inflammation is triggered by an immunoglobulin E (Ig E) response to an extrinsic protein which brings about a complex interaction of inflammatory mediators.
  • The tendency to develop this reactions to allergens has a genetic component. When susceptible individuals are are exposed to certain allergens, there is sensitization. This sensitization is characterized by production of specific IgE to act against these allergens. This IgE are present in the surface of mast cells which are seen in the mucosa of the nose. When the allergen, like a pollen, is inhaled, it binds to the IgE on the surface of the mast cells and causes immediate or delayed release of inflammatory mediators like histamine and kinins. The mast cells then synthesize other mediators like prostaglandins and leukotrienes. These mediators, following some complex interactions will cause the symptoms that are seen in allergic rhinitis [5].
  • Stimulation of mucus glands will lead to increased secretions and increased vascular permeability will lead to plasma exudation. The will be congestion due to vasodilation, pruritus from stimulation of sensory nerves and these events can occur in minutes that’s why it is called immediate inflammatory reactions.
  • These mediators then, through a complex interplay, will lead to recruitment of the delayed inflammatory mediators like neutrophils and lymphocytes to the nasal mucosa. This takes up to 8 hours to occur and may last for days and are called the late inflammatory reaction [6].

Prevention

Prevention involves reduction of exposure to known allergens as much as possible and regular use of drugs [10].

Summary

Allergic rhinitis is popularly called "Hay fever". This is because it is triggered by some precise seasonal plants that are mostly prevalent during the haying season. It is however possible to suffer from this condition throughout the year, haying season or not [1].

Patient Information

  • Definition: Allergic rhinitis is an inflammation of the nasal mucosa caused by the response of a hyperactive immune system.
  • Cause: It is mainly caused by pollens from plants, flowers, grasses and weed, but can also be caused by exposure to outdoor molds, as well as house dust mites, rodents, cockroaches and household pets like dogs and cats. Some of these allergens are used to make fragrances and allergic reactions to perfumes have been reported.
  • Symptom: This will present with symptoms like, itchy nose, runny nose, postnasal drip, and nasal congestion. Other symptoms are headache, earache, red eyes, itchy eyes, drowsiness, fatigue and a general feeling of unwell.
  • Diagnosis: This is done with the help of certain tests to check what causes the allergic reaction. Laboratory investigations are also done to check the levels of some inflammatory mediators as well as imaging like X-rays and CT scan to examine the surrounding structures and rule out complications.
  • Treatment: This involves avoiding the allergen when it has been detected, using drugs to control the hyperactive immune system and immunotherapy.

References

Article

  1. Thompson AK, Juniper E, Meltzer EO. Quality of life in patients with allergic rhinitis. Ann Allergy Asthma Immunol. Nov 2000;85(5):338-47; quiz 347-8.
  2. Matheson MC, Dharmage SC, Abramson MJ, et al. Early-life risk factors and incidence of rhinitis: results from the European Community Respiratory Health Study--an international population-based cohort study. J Allergy Clin Immunol 2011; 128:816.
  3. D'Alonzo GE Jr. Scope and impact of allergic rhinitis. J Am Osteopath Assoc 2002; 102:S2.
  4. Settipane RA. Demographics and epidemiology of allergic and nonallergic rhinitis. Allergy Asthma Proc 2001; 22:185.
  5. Skoner DP. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol. Jul 2001;108(1 Suppl):S2-8
  6. Hansen I, Klimek L, Mosges R, Hormann K. Mediators of inflammation in the early and the late phase of allergic rhinitis. Curr Opin Allergy Clin Immunol. Jun 2004;4(3):159-63.
  7. Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol 2008; 122:S1.
  8. Platts-Mills TA. Allergen avoidance. J Allergy Clin Immunol. Mar 2004;113(3):388-91.
  9. Weber RW. Immunotherapy with allergens. JAMA. Dec 10 1997;278(22):1881-7.
  10. Hadley JA. Evaluation and management of allergic rhinitis. Med Clin North Am. Jan 1999;83(1):13-25.

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Last updated: 2018-06-22 06:19