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Rhinitis, Allergic

BASICS

  • Definition: IgE-mediated inflammation of the nasal mucosa after exposure to allergens (e.g., pollen, dust, dander).
  • Types: Classified as seasonal (outdoor allergens, e.g., pollens) or perennial (indoor allergens, e.g., dust mites, animal dander). Occupational and nonallergic (e.g., vasomotor) rhinitis exist.
  • Symptoms: Sneezing, congestion, rhinorrhea, nasal/ocular/pruritus, postnasal drip.
  • Pathophysiology: Immediate phase (sneezing, rhinorrhea), late phase (congestion, hyperreactivity).

EPIDEMIOLOGY

  • Age of Onset: Usually 8–11 years; rarely <6 months; 80% have onset by age 20.
  • Prevalence: 10–25% of US adults, 9–42% of children.
  • Mixed Rhinitis: Most patients have both allergic and nonallergic components.

ETIOLOGY & PATHOPHYSIOLOGY

  • Mediators: Aeroallergen-driven, with cytokines and inflammatory cells.
  • Common Allergens:
  • Perennial: House dust mites, molds, animal dander, cockroach.
  • Seasonal: Pollens (tree, grass, weed), outdoor molds.
  • Occupational: Latex, flour, chemicals, animals.

RISK FACTORS

  • Family history of atopy (risk ↑ if both parents affected)
  • Higher socioeconomic status, male sex
  • Exposure to tobacco smoke, pollutants, pets, cockroaches
  • Early introduction of solid foods (uncertain risk)

PREVENTION

  • Primary: No strong evidence for maternal diet/allergen avoidance.
  • Exclusive breastfeeding to 6 months may lower risk.
  • First-line: Environmental control/avoidance of allergens.
  • Air conditioning, HEPA filters, closing windows/doors during pollen season, dehumidifiers.

ASSOCIATED CONDITIONS

  • Asthma, atopic dermatitis, allergic conjunctivitis, food allergy

DIAGNOSIS

  • Clinical Diagnosis: Based on history (congestion, sneezing, pruritus, triggers) and physical findings.
  • Physical Exam: Allergic shiners, transverse nasal crease, pale/boggy mucosa, clear rhinorrhea, postnasal drip, oropharyngeal lymphoid hypertrophy.
  • Pediatric: Chronic obstruction can cause facial/dental changes, sleep disorders.
  • Pregnancy: Rhinitis often worsens in 2nd trimester.

Differential Diagnosis

  • Infectious rhinitis, sinusitis, rhinitis medicamentosa, vasomotor rhinitis, hormonal rhinitis, NARES, gustatory rhinitis, nasal polyps/tumor, adenoidal hypertrophy, septal deviation.

Diagnostic Tests

  • Not routinely needed.
  • Allergen skin testing or RAST if considering immunotherapy or unclear diagnosis.
  • CBC (eosinophilia), serum IgE, nasal smear (eosinophils).
  • Antihistamines suppress skin test reactivity—stop 7 days before testing.

TREATMENT

Three Main Approaches

  1. Allergen Avoidance
  2. Limit exposure (indoor allergens, pollen, workplace triggers)
  3. Medication
  4. First-Line:
    • Mild/Moderate: 2nd-generation nonsedating antihistamines (cetirizine, fexofenadine, loratadine, levocetirizine)
    • Moderate/Severe: Intranasal corticosteroids (beclomethasone, budesonide, fluticasone, mometasone, triamcinolone)
    • Use after showering, avoid septum, daily use more effective
    • Intranasal antihistamine or steroid sprays also effective
  5. Second-Line:
    • Nasal antihistamines (azelastine, olopatadine)
    • Intranasal anticholinergics (ipratropium)
    • Leukotriene antagonists (montelukast), esp. with asthma
    • Mast-cell stabilizers (cromolyn): optimal effect after 2–4 weeks
    • 3rd-gen antihistamines, decongestants (phenylephrine, pseudoephedrine, oxymetazoline ≤3 days)
    • Nasal saline sprays/irrigation
  6. Adjuncts:
    • Systemic steroids for urgent, short-term use only
    • Biologics (omalizumab, dupilumab) for severe asthma/rhinitis
  7. Immunotherapy
  8. Subcutaneous injection of specific allergens (desensitization)
  9. Consider if refractory to maximal medical management or with comorbid asthma

Additional

  • Nasal saline irrigation as sole or adjunctive treatment (daily or bid)
  • Start intranasal steroids with 2 sprays/nostril for 2 weeks, then decrease to 1 spray daily
  • "5 days on, 2 days off" steroid spray to minimize side effects

ISSUES FOR REFERRAL

  • Consider allergist referral for immunotherapy or complex/refractory cases

ONGOING CARE

  • Diet: Pollen-sensitive individuals may have oral allergy syndrome with certain fruits/veggies.
  • Education: Environmental control, medication adherence.

PROGNOSIS

  • Aim: acceptable control of symptoms, reduction of risk for sinusitis, asthma.
  • Treatment improves quality of life and decreases complications.

COMPLICATIONS

  • Sinusitis, otitis media, epistaxis, lymphoid hyperplasia, airway hyperreactivity, asthma, sleep/facial changes (mouth breathing)

ICD-10 CODES

  • J30.89: Other allergic rhinitis
  • J30.81: Allergic rhinitis due to animal hair/dander
  • J30.2: Other seasonal allergic rhinitis

CLINICAL PEARLS

  • Nasal saline irrigation (6–8 oz) before corticosteroids may enhance efficacy.
  • 2nd-generation antihistamines and intranasal corticosteroids are first-line.
  • Avoid decongestant sprays >3 days (risk of rebound rhinitis).