Definition
A.Allergic rhinitis is a chronic or recurrent condition characterized by nasal congestion, clear nasal discharge, sneezing, nasal itching, conjunctival itching, and periorbital edema. It usually occurs seasonally after exposure to allergens (same time every year, associated with pollen count), or it may be perennial (year-round, related to indoor inhalants, animal dander, and mold). Allergic
suggests that a specific immunoglobulin E (IgE) antibody mediates the condition.
Incidence
A.Prevalence varies according to geographic region; 10% to 30% of adults have allergic rhinitis. In 80% of the cases allergic rhinitis develops before age 20.
B.Intranasal corticosteroid sprays are recommended for adolescents 12 years of age or older as initial treatment, instead of combination therapy with antihistamines and/or leukotriene antagonists.
C.Allergic rhinitis is a risk factor for obstructive sleep apnea.
Pathogenesis
A.This is an IgE-mediated inflammatory disease involving nasal mucosa; IgE antibodies bind to mast cells in the respiratory epithelium, and histamine is released. This results in immediate local vasodilatation, mucosal edema, and increased mucus production.
Predisposing Factors
A.Genetic predisposition to allergy.
B.Exposure to allergic stimuli: Pollens, molds, animal dander, dust mites, and indoor inhalants.
Common Complaints
A.Nasal congestion.
B.Sneezing.
C.Clear rhinorrhea.
D.Coughing from postnasal drip.
E.Sore throat.
F.Itchy, puffy eyes with tearing.
Other Signs and Symptoms
A.Dry mouth from mouth breathing, snoring.
B.Sleep disturbance due to difficulty with breathing, leading to malaise/fatigue.
C.Itchy nose.
D.Loss of smell and taste.
E.Eczema rash.
F.Shortness of breath, difficulty breathing, and wheezing.
G.Headache.
H.Halitosis.
Subjective Data
A.Ask about onset, course, and duration of symptoms.
B.Inquire about characteristics of nasal discharge.
C.Inquire about exposure to people with similar symptoms.
D.Ask about seasonal impact on symptoms.
E.Inquire about other diseases caused by allergens, such as asthma, eczema, and urticaria.
F.Rule out pregnancy.
G.Ask female patients about their birth control method, specifically birth control pills.
H.Review exposure to irritants.
I.Ask about any past or recent nasal trauma.
Physical Examination
A.Vital signs: Temperature, blood pressure, pulse, and respirations.
B.Inspect:
1.Examine face. Note Dennie’s lines (skin folds under eyes) and allergic salute (transverse crease on nose from chronic rubbing of nose).
2.Examine eyes and conjunctivae:
a.Tearing; red, swollen eyelids; and allergic shiners (dark circles under eyes from venous congestion in maxillary sinuses) are seen with allergies.
b.Palpebral conjunctiva pale and swollen, bulbar conjunctiva is injected.
3.Examine ears, nose, and throat:
a.Red, dull, bulging, perforated tympanic membrane is seen with otitis media.
b.Nasal redness, swelling, polyps, and enlarged turbinates are seen with upper respiratory infection (URI). Mucosa appears pale blue, boggy with clear discharge in chronic allergy.
c.Cobblestone appearance in pharynx, tonsils, and adenoids seen in chronic allergies.
d.Use otoscope light to transilluminate under superior orbital ridge of frontal sinus cavity and also maxillary sinus cavity to assess for fluid in sinus cavity. Healthy sinuses contain air and light up symmetrically.
C.Palpate:
1.Palpate face and frontal maxillary sinuses for tenderness.
2.Examine head and neck for enlarged lymph nodes.
D.Percuss:
1.Percuss sinus cavities and mastoid bone.
2.Percuss chest for consolidation.
E.Auscultate: Auscultate heart and lungs.
Diagnostic Tests
Diagnosis may be made from history and physical. Other diagnostic tests include the following:
A.Wright’s stain of nasal secretions: Presence of eosinophils confirms allergy, but may be normal.
B.Skin testing for allergies.
C.Radioallergosorbent test (RAST).
D.Complete blood count (CBC) with increased eosinophils (confirm allergy).
Differential Diagnoses
A.Allergic rhinitis.
B.URI.
C.Medication-induced rhinitis.
D.Sinusitis.
E.Otitis media.
F.Deviated septum.
G.Nasal polyps.
H.Endocrine conditions such as hypothyroidism.
I.Influenza.
Plan
A.General interventions:
1.Avoid allergens (most effective treatment).
2.Keep bedroom as allergen-free as possible.
B. 
See Section III: Patient Teaching Guide Allergic Rhinitis.
C.Pharmaceutical therapy:
1.Antihistamines* (H1 receptor antagonists, second generation) are drugs of choice. Several may need to be tried before an effective one is found. Drugs may also need to be switched occasionally to prevent tolerance:
a.Azelastine HCl (Astelin) metered nasal spray: 137 mcg per metered dose. Adults: Two sprays per nostril twice daily.
b.Loratadine (Claritin): 10 mg by mouth daily (adults).
c.Desloratadine (Clarinex): 5 mg by mouth daily (adults).
d.Fexofenadine HCl (Allegra): 60 mg capsules orally twice daily or 180 mg daily.
e.Cetirizine HCl (Zyrtec):
i.Adults: 5 to 10 mg by mouth daily depending on symptom severity.
ii.Lower dose of 5 mg daily for patients with renal or hepatic impairment.
f.Levocetirizine dihydrochloride (Xyzal): Adults: 2.5 to 5 mg daily in p.m. Precautions for renal impairment.
2.Intranasal steroid sprays may be used to decrease nasal inflammation. Sprays do not cause significant systemic absorption in usual doses, but occasionally they may cause pharyngeal fungal infections:
a.Beclomethasone dipropionate (Beconase AQ, Vancenase). Adults: One to two sprays in each nostril twice daily.
b.Fluticasone propionate (Flonase). Adults: Two sprays daily or one spray twice daily. Maintenance dosing: One spray in each nostril daily.
c.Triamcinolone acetonide (Nasacort AQ). Adults: Two sprays daily.
d.Mometasone furoate (Nasonex). Adults: Two sprays each nostril once daily.
e.Fluticasone furoate (Veramyst):
i.Adults: Two sprays each nostril daily.
ii.Maintenance: One spray each nostril daily.
f.Budesonide (Rhinocort Aqua). Adults: Two sprays twice daily.
g.Qnasl (beclomethasone dipropionate). Adults: Two sprays each nostril once daily; maximum four sprays per day.
3.Topical decongestants for significant congestion of the mucous membranes.
These drugs may also stimulate the sympathetic nervous system and cause insomnia, nervousness, and palpitations. Use no longer than 3 to 5 days. Discontinuing these drugs after 5 days may result in a rebound effect:
a.Oxymetazoline hydrochloride (Afrin) spray or drops. Adults: Two to three drops or sprays of 0.05% solution in each nostril twice daily.
b.Phenylephrine (Neo-Synephrine) spray or drops. Adults: Two to three drops or one to two sprays in each nostril, or small amount of jelly applied to nasal mucosa, every 4 hours as needed. Do not use for more than 3 to 5 days.
4.Leukotrine antagonist: Act by blocking the chemical reaction that leads to the inflammatory process:
a.Montelukast (Singulair). Adults: 10 mg tablet daily.
5.First-generation antihistamines (e.g., diphenhydramine, brompheniramine) may be used. Precautions should be discussed regarding the possibility of sedation and performance impairments.
6.Saline spray:
a.Saline spray is effective in liquefying thick secretions and helps keep mucosa moist.
b.Use neti pot or sinus rinse with warm saline water to cleanse inside of nasal mucosa; daily use is suggested.
7.Petroleum jelly applied with Q-tip to inside mucosa of nares three to four times a day helps to provide lubrication and hold in moisture to prevent nasal dryness and bleeding.
Follow-Up
A.Patient should return for follow-up visit in 2 to 3 weeks if necessary, earlier if symptoms worsen after 3 days of treatment.
Consultation/Referral
A.Refer the patient to an allergist if symptoms continue and interfere with daily activities.
B.Allergist may prescribe immunotherapy following identification of offending allergens.
Individual Considerations
A.Pregnancy:
1.Over-the-counter (OTC) antihistamines such as diphenhydramine HCl (Benadryl) may be used for up to 5 days.
2.OTC decongestants such as oxymetazoline HCl (Afrin) may be used up to 3 days.
B.Geriatrics:
1.Beers considerations:
a.Antihistamines are effective for this population; however, there are more side effects and drug interactions in this group. Consider age and possible drug–drug interactions when prescribing medications for allergic rhinitis.
b.Anticholinergic effects in elderly are sedation, bladder/bowel retention, confusion, delirium, high risk for falls, and accident prone.
c.Acetylcholinesterase inhibitors often prescribed for cognitively impaired geriatrics will increase anterior rhinorrhea.
d.Best tolerated medications for the elderly population that offer fewer side effects include the following:
i.Intranasal steroid sprays (limited use).
ii.Nasal normal saline.
iii.Most second-generation antihistamines such as cetirizine, fexofenadine, and loratadine.
iv.Limited Benadryl might be appropriate for an acute, severe allergic reaction.
2.Studies show that sleep disordered breathing is more prevalent in the elderly with allergic rhinitis. Sleep efficiency was lower and waking after sleep onset was longer. It is imperative that clinicians obtain a thorough sleep history and assess for any signs/symptoms of sleep deprivation and decrease cognitive alertness with this population to maintain safety and quality of life.
3.Elderly population between ages 60 and 75 years old tend to be undertreated. Studies indicate that oral antihistamines and nasal glucocorticosteroids are effective and safe if the patient has few comorbidities and no current history of polypharmacy.
4.Common allergens for geriatrics with persistent allergic rhinitis are house dust mites, pet dander, and cockroach allergens. Assessment of elderly home environments and living conditions could initiate improved quality measures and decrease risk of allergic outbreaks.