Allergic Rhinitis

Mitchell R. Lester
Allergic Rhinitis - Introduction
Abbreviations used:
AIT: Allergen immunotherapy
AR: Allergic rhinitis
IgE: Immunoglobulin E
INS: Intranasal corticosteroid
LTRA: Leukotriene receptor antagonist
RAST: Radioallergosorbent test
SCIT: Subcutaneous immunotherapy
SLI: Sublingual immunotherapy

Up to 20% of the population suffers from allergic rhinitis (AR) and many fail to recognize that the effects of AR reach far beyond the nose. The total direct and indirect costs of AR in the United States exceed $15 billion dollars annually, indicating that the condition affects the entire economy, not just the individual.
In addition to its well-known co-morbidities of recurrent otitis media, sinusitis, cough, and asthma, AR has a tremendous impact on quality of life including school absence and poor performance. As a result, it is often necessary to treat AR as a chronic, not an episodic disease.

Allergic rhinitis is “a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose” (J Allergy Clin Immunol. 2001;108:S147). What does that mean? If symptoms are present without the presence of allergen-specific IgE or there is allergen specific IgE without symptoms, technically the patient should not be diagnosed with allergic rhinitis. Of course, the presence of specific IgE is often assumed based on the history.

When assessing a patient for allergic rhinitis and before formulating a treatment plan, I consider several key points:
1. What are the symptoms?
2. What is the timing of the symptoms in relation to exposure to aeroallergens?
3. Other than the obvious nasal symptoms, is there coughing, need for antibiotics, or other systemic complaints or concerns?
4. The physical exam.
5. What treatments have already been used and how effective were they?
6. And finally, testing for specific IgE is performed.

The symptoms and signs of AR include itchy nose, throat/palate, eyes (allergic conjunctivitis), and pruritus inside the ears. There is frequently nasal congestion, sneezing, and clear, watery nasal discharge. Some patients also demonstrate an allergic salute, in which they use the palm of the hand to push the nose upward, an allergic “grimace,” and a “clucking sound”.

Triggers of AR are either seasonal or perennial, although many patients have perennial AR with seasonal worsening. Aerobiology varies by geographic region. Most perennial allergens are indoors although outdoor molds (fungi) may be present year round. Indoor (perennial) allergens include dust mites, molds, animal dander especially from house pets, cockroaches, and rodents. Although there is some seasonality in the level of outdoor molds, most seasonal allergens are pollen, the presence of which depends on the flora of your region.

Allergens as triggers to AR are called “specific” and are related to the presence of IgE (the “allergy” antibody) with affinity for that allergen. That is, if you are allergic to cats but not dogs, exposure to cats but not to dogs will trigger symptoms. In contrast, there are also “non-specific” triggers to AR that can elicit worsening symptoms in anyone already affected, independent of to what he or she is allergic. Non-specific triggers of AR are considered irritants and include strong odors (such as from cleaning supplies, paint, industrial odors), outdoor and indoor air pollution (such as cigarette smoke, fire places, wood burning or kerosene stoves), and irritant dusts as may be found with home construction or just very dusty areas. Control of the symptoms triggered by specific allergens usually helps mitigate the effects of irritant, non-specific triggers of AR.

Allergic Rhinitis Allergic Rhinitis 09/06/2018
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