Hay Fever and Rhinitis

Allergic Rhinitis can manifest with a variety of symptoms-

-itchy watery eyes

-runny nose

-sneezing

-nasal congestion

-throat irritation

-thin post nasal drainage

-mouth breathing

are just a few of the symptoms.

Allergic rhinitis affects approximately 10-20% of the adult population and approximately 40%of the pediatric population

There are certain findings which we look for during your office visit to confirm the diagnosis. In addition to providi ng a history consistent with either seasonal symptoms ( seasonal allergic rhinitis) or year round symptoms ( perennial allergic rhinitis).

Seasonal allergic rhinitis is often related to outdoor allergens such as trees, grasses and ragweed. These often affect patients in the late winter (trees in February thru May) early spring ( grasses May thru June/July) and late summer,fall (weeds July thru September/October)

Nasal findings suggestive of allergy include external signs such as a horizontal supratip crease, which results from a gesture known as the “allergic salute.” This gesture involves using the palm of the hand to push the nasal tip upward, which serves the dual purpose of temporarily opening the nasal airway and alleviating the nasal itch. This is also used by children as a maneuver to tackle rhinorrhea. Frequent saluting for 2 years or more is sufficient to make this crease permanent. Other external signs include erythema of the philtrum due to chronic nasal drip and irritation, as well as crusting or frank nasal discharge. Anterior rhinoscopy performed with a headlight and a nasal speculum is also an essential component of the physical exam. Characteristic findings in the patient with nasal allergy include pale, edematous turbinate mucosa, enlarged turbinates, and abundant clear nasal secretions. These findings are distinct from the nasal findings in other disorders. Rhinitis medicamentosa, the rebound rhinitis caused by overuse of topical decongestants such as over-the-counter nasal sprays or cocaine, causes the nasal mucosa to appear atrophic, dry, erythematous, and friable ¹¹. Posterior rhinoscopy must be performed using either flexible or rigid telescopes. Findings in the posterior nasal cavity that are consistent with, but not diagnostic for, nasal allergy include cobblestoning of the mucosa or nasal polyposis. One may also see clear mucosal streaking between the turbinates and septum on nasal endoscopy. Nasal polyps may arise from causes other than allergy; for example, they are found as a part of Samter’s triad, which includes aspirin sensitivity and asthma in addition to nasal polyposis. Nasal polyps caused by allergy are expected to be bilateral, as the hypersensitivity is systemic.

Although the facial appearance (eyes and nose) manifest allergic signs the most, the remainder of the physical exam is also important. Oral cavity manifestations include dry chapped lips, a high-arched palate caused by long-term mouth breathing, as well as foul breath and dental caries caused by pH changes. Oropharyngeal findings of allergies include enlarged or cryptic tonsils from the recurrent infections and cobblestoning of the oropharyngeal mucosa due to hypertrophy of small patches of submucosal lymphoid tissue ¹¹. Laryngeal findings in allergy may include thick mucus overlying the vocal folds, mild edema of the vocal folds, and erythema of the arytenoids.

Treatment of allergic rhinitis

To test or not to test

The first-line treatments for allergic rhinitis include nasal steroids and nonsedating antihistamines. These medications have few side effects, are relatively inexpensive, and are also efficacious

Allergen Avoidance

Allergen avoidance is often recommended as one of the first-line treatments for allergic rhinitis. Avoiding allergen exposure may be one of the most effective and cost-effective management strategies. Simple strategies such as limiting pollen exposure by closing windows, using an air conditioner, or encorporating a high efficiency particulate arresting (HEPA) filter. Dust mites, another common allergen, may be avoided by using allergen-impermeable covers on bedding and pillows, washing bedding in at least 150 Fahrenheit temperatures, or replacing bedding frequently. More thorough elimination of environmental allergens, however,may require removing carpets, curtains, and even pets from the home. The bedroom should be an area which is the “allergy free” focus as this is the region where most working people spend the majority of their time. Occasionally avoidance steps are less practical as initial avoidance techniques, and are best used after allergy testing has definitively identified the allergen to be avoided

Medical Treatment

The available medications include oral and topical antihistamines, oral or topical corticosteroids, oral of topical decongestants, topical nasal cromolyn, topical anticholinergics, and antileukotrienes.

Antihistamines

Oral antihistamines have been very effective in the treatment of allergic rhinitis. Because histamine is largely responsible for the early allergic response, antihistamines are most effective at blocking the sneezing, itching, and rhinorrhea that characterize this response Antihistamines are only minimally effective at controlling nasal congestion. The side effect of sedation that characterized the first-generation antihistamines has been virtually eliminated in the second-generation antihistamines,. Antihistamines are available in oral and topical forms, and are useful as first-line treatment for mild or intermittent allergic rhinitis. In more severe or chronic allergic rhinitis, where nasal congestion is a prominent complaint, other treatment options in combination with or in lieu of antihistamines are more appropriate.

Corticosteroids

Topical corticosteroids are the most effective of the first-line agents approved to treat allergic rhinitis, Although they are used primarily to treat nasal congestion, some reports indicate that they may also control eye symptoms in addition to treating sneezing, rhinorrhea, and nasal itch Topical corticosteroids are useful as a first-line treatment for severe allergic rhinitis or allergic rhinitis refractory to initial treatment. Unlike antihistamines, corticosteroids do not prevent the allergic event, but decrease the effects of the allergic response by decreasing the release of pro-inflammatory mediators . Minor side effects such as nasal irritation, burning, epistaxis, sore throat and foul taste may be minimized with thorough instructions on proper use of these topical sprays.

Anticholinergics

The main role of intranasal ipratropium is for controlling rhinorrhea. Many of the other agents described above are also effective at controlling this symptom, therefore the main role of this medication is as an adjunctive medication for refractory allergy symptoms .

Decongestants

Nasal congestion can be a prominent and troublesome symptom of allergic rhinitis. In addition, nasal congestion predisposes to the development of related symptoms such as sinusitis and serous otitis media. Although chronic nasal congestion is best treated with intranasal corticosteroids or immunotherapy, nasal congestion in the setting of acute sinusitis is best treated aggressively with an oral or topical decongestant. Oral decongestants may also be useful on a daily basis during a period of intense allergen exposure, and for this purpose the patient may prefer the convenience of combined oral antihistamine/decongestant combinations. Topical nasal decongestants (oxymetazaline/neosynyephrine) are also available and are very effective, however, use of topical decongestants for 5 days or more can cause rebound rhinitis (rhinitis medicamentosa). Oral decongestants need to be used cautiously secondary to their system side effects. This is especially true in patients with hypertension, benign prostatic hypertrophy and cardiovascular disease.

Allergy Testing

Allergy testing is indicated when a patient’s symptoms are not controlled by routine medical therapies. Allergy tests are used to determine the specific antigens that trigger the allergic response in the patient. This in turn allows treatment or allergen-avoidance to be antigen-specific

Non-allergic rhinitis is a set of symptoms resembling an allergy but occur in the absence of any known allergy. Generally developing in adulthood, symptoms persist all year round. The symptoms include postnasal drip, sneezing, runny nose and stuffy nose. Approximately 19 million people in the U.S. have non-allergic rhinitis as compared to approximately 50 million who suffer from allergic rhinitis.

Symptoms and signs

Non-allergic rhinitis is not associated with your immune system, but it can make you feel just as miserable as with allergic rhinitis or hay fever. Both kinds of rhinitis can be associated with lowered work productivity, increased trips to the doctor’s office and side effects from treatment (nosebleed, drowsiness and dryness of the nasal passages). Since these two conditions are so much alike, allergy tests and blood tests are often needed to differentiate them. Symptoms and signs of rhinitis include:

Itchy, watery eyes
Nasal congestion from inflammation and swelling of the tissues lining the sinuses
Ear pain from dysfunction of the Eustachian tubes
Chronic ear infections
Loss of smell or taste
Asthma symptoms (like wheezing and cough)
Obstructive sleep apnea and snoring

When it comes to relieving bothersome symptoms of non-allergic rhinitis, the most effective treatment method is to avoid your individual triggers as much as possible. If you or someone you love suffers from rhinitis, call today for a consultation with one of our caring ENT specialists. The doctor can help you find a solution to your symptoms.