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Allergic rhinitis

Inflammation of the nasal mucosa due to an allergic reaction to environmental factors. Two types - seasonal due to allergy to pollen and moulds; perennial due to allergy to factors such as house dust mite, pet dander and occupational chemicals, e.g. flour, rubber gloves (common in the hospital staff).

Epidemiology Affects10-15% UK population, family atopic history common. Can develop at any age but 80% cases appear by age 20 years.

Presentation
Symptoms Nasal itching, sneezing, watery discharge and blockage. Seasonal form starts spring to early summer. May be associated with eye symptoms or wheezing.
Signs Local examination with head mirror and speculum or ophthalmoscope with auroscope attachment - mucosa pale bluish with "boggy" appearance in allergic conditions, red and inflamed with pus suggests infection. Granular appearance with fine pale nodules indicates sarcoidosis. Do not confuse enlarged turbinates with polyps - distiction not always easy, in secondary care use endoscope to confirm diagnosis if in doubt. Test sense of smell, examine eyes, ears, mouth and throat as well as chest and give general examination.

Differential Diagnosis

• Infection - suggested by facial pain, fever, feeling unwell, mucopurulent discharge.
• Granulomatosis conditions (Wegener's syndrome) or atrophic rhinitis - suggested by in nasal crusting and/or bleeding.
• Tumour (rare) - crusting/bleeding, persistent unilateral symptoms.
• Polyps/trauma - impaired taste/smell
• Drug related - beta blockers, ACE inhibitors, cocaine, NSAID's.
• Hormonal - pregnancy/pre-menstrual, puberty, oral contraceptives, and hypothyroidism.
• Nasal foreign bodies.
• Occupational rhinitis - due to an allergic or non-allergic reaction to airborne substances in the workplace.
• Idiopathic - vasomotor rhinitis (non-allergic perennial rhinitis) - may develop symptoms to environmental factors eg cold weather, high humidity etc..

Investigations Skin prick test or allergy-specific IgE serum test is not essential but may help in exclusion of allergens.

Associated Diseases Asthma, eczema, abnormality of mucus (Young's syndrome, cystic fibrosis), ciliary dysfunction, recurrent/chronic symptoms may indicate immune deficiency states, hormonal conditions (PMS, pregnancy, hypothyroidism, acromegaly).

Management

• Non-Drug Search for the allergic trigger: seasons, relation to work, pets. Symptoms may be delayed several hours after exposure. Avoidance of provoking allergens, e.g. pollen, mite-proof bedding, removing bedroom carpet or pets (or wash).
  Refer to ENT consultant patients with unilateral nasal symptoms, nasal perforation, ulceration or collapse, bloody discharge, crusting in high nasal cavity, recurrent infection, peri-orbital cellulitis (consider urgent).
• Drugs
  • Mild: First line - local or oral antihistamines prn, second line - add local corticosteroid or cromoglycate. Stop antihistamines when control achieved on corticosteroids.
  • Moderate: regular local corticosteroid or cromoglycate, second line - add local or oral antihistamines.
  • Severe: 2 weeks oral corticosteroids plus local corticosteroid drops, then regular corticosteroid spray ± regular or prn oral antihistamines. Consider referral for immunotherapy for pollen sensitive patients.

Treating rhinitis can often improve control of co-existing asthma.

Complications Sinusitis, nasal polyposis, dental problems, chronic otitis media.

Prognosis Symptoms decrease as patient get older.

Prevention Avoid allergens as above.

References Used

1. Conner SJ. Evaluation and treatment of the patient with allergic rhinitis. J Fam Pract. 2002; 51(10): 883-90.
2. Prodigy Guidance - Allergic Rhinitis A good detailed review of the subject with references.
3. MIMS January 2003

Internet and Further Reading

• General Practitioners in Asthma Group - information sheet (1999)

Acknowledgements EMIS is grateful to doctoronline.nhs.uk for facilitating draft authoring of this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2003.

Last issued 15 Aug 2005