Khaled R. Girgis, MD, PhD
Allergist and Clinical
Immunologist
College Park Family Care Center
12208 W 87th Street
Lenexa, KS 66215
Allergic Rhinitis
Everything you need to know,
almost
Allergic Rhinitis, Facts
• More than 50 million Americans suffer
from allergies
• Sixth leading chronic disease in U.S.
• 4.5 billion dollars in health care costs
annually
• 3.8 million days lost yearly (from work and
school)
What is Rhinitis?
• The nasal passages are lined with a membrane
•
that produces mucus
Mucus is one of the body's defense systems:
– Thin clear liquid, traps small particles and bacteria
– The trapped bacteria usually remain harmless in
healthy individuals
– Even under normal circumstances, this produces a
cycle of congestion and decongestion that occurs
continuously throughout the day
• When one side of the nose is congested, air
passes through the open, or decongested, side.
The sides alternate between being wide open
and being narrowed
Allergic Rhinitis:
Effect On Quality of Life
• People with perennial allergic rhinitis, may
experience sleep disorders and daytime fatigue.
– Often they attribute this to medication, but studies
suggest congestion may be the culprit in these
symptoms.
• Patients with seasonal allergies experience
hundreds of brief, subtle awakenings, called
"microarousals", each night. In such cases,
people are not aware that they wake up, but
such events can cause fatigue the next day.
Allergic Rhinitis:
Effect On Quality of Life
• Children with severe allergies may have a higher risk for behavioral
problems than those without allergies
• There have been reports that 30% to 45% of people with allergic
rhinitis also suffer from ear infections (otitis media)
• Chronic nasal obstruction can affect a child's appearance. If a child
can only breathe through the mouth, this might lead to an
elongated face and an overbite from teeth coming in at an abnormal
angle
• Chronic rhinitis can cause headaches and also affect a child's sleep,
concentration, hearing, appetite, and growth
Allergic Rhinitis: Risk Factors
• Increasing age, atopy, and high
socioeconomic status
• Parental history is also positively
associated with development of allergic
rhinitis. A maternal history of allergy was
significantly associated with a diagnosis of
rhinitis by age 6 years
• Other risk factors include indoor and
outdoor air pollution
Sagittal view of the inside of the nasal cavity
Allergic Rhinitis: Mechanism
Allergic Rhinitis: Symptoms
• Rhinitis develops when congestion becomes severe or
•
other changes occur that irritate the nasal passage
Patient must experience at least two of the following
symptoms for an hour or more on most days:
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–
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Runny nose
Obstruction in the nasal passage
Nasal itching
Sneezing
• These symptoms may occur as a result of colds or
environmental irritants, such as allergens, cigarette
smoke, chemicals, changes in temperature, stress,
exercise, or other factors
The Allergic Appearance:
Allergic shiners related to chronic nasal congestion
Mouth breathing and a gaping mouth
The Allergic Salute
Nasal itching causes repeated wiggling of the nose
(bunny nose), or wiping and pushing of the nose
Chronic Rhinitis
• When rhinitis lasts for a long period, it is
most often caused by allergies but can
also be caused by structural problems or
chronic infections.
Chronic Rhinitis Not Related to Allergies
• Aging Process
• Mucous membranes become dry with age
• Cartilage supporting the nasal passages
•
weakens, causing changes in airflow
Therapy:
Avoid possible allergens and airborne irritants
and keep the nasal passages moist.
Decongestants would not be appropriate
Vasomotor Rhinitis: Chronic Rhinitis
Not Related to Allergies
• Increased parasympathetic stimulation
• Overreaction to irritants, cigarette smoke,
air pollutants, strong odors, alcoholic
beverages, stress, and exposure to cold
• Gustatory rhinitis
• Not the same as allergic reaction
Chronic Rhinitis Not Related to
Allergies
• Foreign Objects
• Blockage in young children is very often
caused by foreign objects
• If left in place, they may eventually cause
infection and nasal discharge, usually in
one side of the nose, which may be yellow
or green and foul smelling (very)
Chronic Rhinitis Not Related to
Allergies
• Polyps
– soft, fluid-filled sacs
– impede mucus drainage and restrict airflow
– develop from sinus infections, do not regress on their
own and may multiply and cause considerable
obstruction
• Deviated Septum
– A common structural abnormality that causes rhinitis
When deviated, it is not straight but shifted to one
side, usually the left
Nasal Polyps
• Protrude from the sinuses into the nasal
cavities, usually from the middle meatus
• Can be unilateral, or bilateral
• Anosmia, most common presentation
• Very common in CF
– 50% of children (4-16 y/o) w/ nasal polyps
have CF
Rhinitis of Pregnancy
• One in five pregnant women will
experience rhinitis symptoms (2nd or 3rd
trimester)
• Hormonally induced
• Spontaneously resolves within few weeks
after delivery
• Limited therapeutic options
Drug-Induced Rhinitis
Chronic Rhinitis Not Related to Allergies
• Medications and Illegal Drugs
• overuse of decongestant sprays can, over time (three to
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•
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five days), cause inflammation in the nasal passages and
worsen rhinitis, Rhinitis Medicamentosa
Aspirin, Ibuprofen (Motrin, Advil), and Naproxen (Aleve)
For minor pain, Acetaminophen (e.g., Tylenol), is usually
recommended for patients with intolerance to NSAIDs.
Oral contraceptives, hormone replacement therapy, antianxiety agents, some antidepressants, and some blood
pressure medications, including beta-blockers and
vasodilators
Sniffing cocaine damages nasal passages and can cause
chronic rhinitis
Local Allergic Rhinitis
• Patients demonstrate Allergic Rhinitis
symptoms but without other systemic
manifestations
• Negative SPT and negative RAST
• Diagnosis: Nasal provocation and
detection of specific IgE in nasal mucosa
Allergic Rhinitis: Diagnosis
• Allergy Testing
– Skin testing and in-vitro blood testing
– Testing is important to institute specific
avoidance measures
– Skin testing is slightly more sensitive
– Common allergens
• Outdoors: tree, grass, weed pollens, and mold
• Indoors: dust mites, pet dander, cockroaches and
mold
Allergic Rhinitis: Diagnosis
• Imaging studies
– X-rays have a limited value
– CT scans are preferred for evaluation of
sinusitis
• Endoscopy
– Usually performed by an ENT physician,
allows easy evaluation of the nose, and throat
areas
Allergic Rhinitis: Treatment
Avoidance/Indoor Protection
• Pets:
– If patient is allergic to pets, they should be given away or kept
outside
– If this isn't possible, they should at least be confined to carpetfree areas outside the bedroom
– Cats harbor significant allergens, which can even be carried on
clothing; dogs usually present fewer problems
– Washing animals once a week can reduce allergens. Dry
shampoos, such as Allerpet, are now available for pets that
remove allergens from skin and fur and are easier to administer
than wet shampoos.
Allergic Rhinitis: Treatment
Avoidance/Indoor Protection
• Dust Control
– simply using a spray furniture polish is very effective
for reducing both dust and allergens
– Air cleaners, filters for air conditioners, and vacuum
cleaners with HEPA filters can help remove particles
and small allergens found indoors
– Neither vacuuming nor the use of anti-mite carpet
shampoo, however, is effective in removing mites in
house dust. In fact, vacuuming stirs up both mites
and cat allergens
– Carpets and rugs should be avoided if possible
Allergic Rhinitis: Treatment
Avoidance/Indoor Protection
• Bedding and Curtains
– Using semipermeable coverings to fully
encase mattresses, box-springs and pillows is
the most proven effective step in reducing
dust mite levels
– Curtains should be replaced with shades or
blinds
– Bedding should be washed using the highest
temperature setting
Allergic Rhinitis: Treatment
Avoidance/Indoor Protection
• Reducing Humidity in the House
– Dust mites thrive in humidity and damp
houses increase the risk for mold
– On-going humidifiers, then, can be
counterproductive. If they are used, humidity
levels should not exceed 40% and they
should be cleaned daily with a vinegar
solution
Allergic Rhinitis: Treatment
Avoidance/Indoor Protection
• Exterminating Pests
– Cockroaches: eliminate by professional exterminators.
(One study reported that ridding a home of
cockroaches and cleaning the house using standard
housecleaning techniques failed to eliminate the
cockroach allergens themselves.)
– Mice should be eliminated, attempts should be made
to remove all dust, which might contain mouse urine
and dander.
Allergic Rhinitis: Treatment
Avoidance/Outdoor Protection
• Camping and hiking trips should not be
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scheduled during times of high pollen count (in
the Northern states, May and June for grass
pollen and mid-August to October for ragweed).
Patients who are allergic to mold should avoid
barns, hay, raking leaves, and mowing grass.
Fungi in car air conditioners can also be a
problem.
Allergic Rhinitis: Medical Treatment
Allergic Rhinitis:
Second-Generation (Nonsedating) Antihistamines
• The newer second-generation antihistamines do not usually cause
drowsiness to the extent that the first generation antihistamines do.
• Brand Names.
– Loratadine (Claritin) is approved for children age two and
over. OTC
– Desloratadine (Clarinex) is similar to Claritin but significantly
more potent and longer lasting. It is available only by
prescription.
– Cetirizine (Zyrtec) is approved for both indoor and outdoor
allergies. It is the only antihistamine to date approved for infants
as young as six months. OTC
– Fexofenadine (Allegra) OTC
– Levocetirizine (Xyzal) only by prescription
• Studies suggest that cetirizine (Zyrtec) is more effective than either
of these other agents in improving symptoms, including in children,
although cetirizine causes more drowsiness at higher doses.
Allergic Rhinitis: Oral Decongestants
• Oral decongestants come in many brands,
which mainly differ in their ingredients.
• The most common active ingredient is
pseudoephedrine (Sudafed, Actifed,
Drixoral). The alternative decongestant,
phenylpropanolamine (PPA) was taken off
the market.
Allergic Rhinitis: Oral Decongestants
• Side Effects of Decongestants
– Agitation and nervousness.
– Drowsiness (particularly with oral
decongestants and in combination with
alcohol).
– Changes in heart rate and blood pressure.
– Avoid combinations of oral decongestants
with alcohol or sedatives.
Allergic Rhinitis: Corticosteroid Nasal Sprays
• Benefits:
– The most effective agents currently available for
treating allergic rhinitis.
– Blocks the inflammatory response that triggers an
allergic attack. They do not relieve symptoms
immediately but may take several hours before their
effects are felt.
– They reduce inflammation and mucus production.
– They improve night sleep and daytime alertness in
patients with perennial allergic rhinitis.
– Beneficial in treating polyps in the nasal passages.
Allergic Rhinitis: Corticosteroid Nasal Sprays
• Corticosteroids available in nasal spray
form include the following:
• Triamcinolone (Nasacort). Approved for children over
six, now OTC!!!
• Mometasone furoate (Nasonex). Approved for use in
patients as young as three.
• Fluticasone (Flonase). Approved for children over
four.
• Budesonide (Rhinocort). Approved for children over
six.
Nasal Antihistamines
• Efficacious and equal to or superior to oral
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•
•
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antihistamines for treatment of SAR
Clinically significant effect on nasal congestion
Improved nasal symptoms in patients who failed
oral antihistamines
Onset of action: 30 vs. 60-180 minutes for oral
antihistamine
Side effects: Sedation, bitter taste
Nasal Antihistamines
• Azelastine 0.1% and 0.15% (Astelin,
Astepro)
• Olopatadine (Patanase)
• Azelastine/Fluticasone (Dymista)
Allergen Immunotherapy
• Criteria for Allergen Immunotherapy
– Severity of rhinitis symptoms
– Duration of rhinitis symptoms
– Progression of rhinitis
– Failure to respond to medical treatment
Allergic Rhinitis: Allergen
Immunotherapy
• Administering Therapy
• Immunotherapy requires a prolonged course of weekly
injections ("allergy shots"). The process generally follows
this course:
– Injections of diluted extracts of the allergen are given on a
regular schedule, usually weekly at first, then in increasing doses
until a maintenance dose has been reached. It usually takes
several months to reach a maintenance dose.
– At that time, intervals between shots can be two to four weeks,
and the treatment is continued for up to three to five years.
– Patients can experience some relief within three to six months; if
there is no benefit within 18-24 months, the shots should be
discontinued.
Allergic Rhinitis:
Conclusions
• Allergic disorders are on the rise and have
a significant impact on the quality of life
• Allergic rhinitis can lead to other
comorbidities such as asthma and sinusitis
• Treatment should focus on trigger
identification and avoidance, medications
and allergen immunotherapy
References
• Dykewicz MS, et al. Ann Allergy Asthma Immunol
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•
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1998;81(5 Pt 2):478-518
Rondon et al. J Investig Allergol Clin Immunol 2010;
20(5): 364-371
Wallace et al. J Allergy Asthma Clin Immunol 2008; 122:
S1-84
M. Varghese, M. C. Glaum and R. F. Lockey, Clinical &
Experimental Allergy, 2010 (40) 381–384