Allergic rhinitis

Question 1

What are the symptoms of allergic rhinitis?

Answer 1

• O – ocular, i.e. allergic conjunctivitis
• S – sneezing
• N – nasal obstruction
• A – ant rhinorrhoea w watery discharge ***
• P – pruritus of nose

Question 2

What are the signs of allergic rhinitis?

Answer 2

Damp, pale nasal lining w swollen oedematous turbinates

If long-standing: hypertrophied turbinates w/ little erectile activity (due to compensatory mechanism to increase surface area for prep of air)

Question 3

What are the atypical symptoms of allergic rhinitis that should point you towards a different dx?

Answer 3

• Unilateral symptoms
• Nasal obstruction w/o other symptoms
• Recurrent epistaxis
• **Facial pain, anosmia, mucopurulent rhinorrhoea or post rhinorrhoea w thick mucous -> sinusitis

Question 4

what are the investigation performed on allergic rhinitis and what is the c/i to the ix?

Answer 4

**Skin prick test: mainly dust mites, pets, types of grass (oral anti-histamines must be stopped >48 hours prior to skin pick test) -> pts can see allergic reaction to the allergens and hence will be more convinced and compliant to meds

C/I to skin prick

(1) antihistamine use within 48 hours (will falsely cause no allergic reaction)
(2) beta blockers, because adrenaline is used to treat anaphylaxis, but this is less effective if the patient is on beta blockers
(3) pregnancy, immunocompromised, cancer patients

Alternatively, antigen-specific IgE (eg RAST) can be used -> more costly, slower (need to wait 2 weeks for report), less sensitive than skin prick test. But, it can be used in patients taking anti-histamines or during pregnancy.

Question 5

What is the management of mild intermittent symptoms?

Answer 5

Not in preferred order

• Oral H1 blocker OR
• intranasal H1 blocker and/or decongestant OR
• LTRA (leukotriene receptor antagonist)

Question 6

What is the management of intermittent moderate- severe symptoms?

Answer 6

Not in preferred order

• Oral H1 blocker OR
• intranasal H1 blocker and/or decongestant OR
• intranasal CS OR
• LTRA (leukotriene receptor antagonist)

Question 7

What is the management of persistent mild symptoms?

Answer 7

Not in preferred order

• Oral H1 blocker OR
• intranasal H1 blocker and/or decongestant OR
• intranasal CS OR
• LTRA (leukotriene receptor antagonist)

Review after 2-4 weeks

• if failure: step up
• if improved: continue for 1 month

Question 8

What is the management of persistent moderate- severe symptoms?

Answer 8

In preferred order:
- Intranasal CS
H1 blocker or LTRA

Review after 2-4 weeks

• if failure: add or increase intranasal CS dose/ rhinorrhea add ipratriopium/ blockage add decongestants or oral CS (short term), if failure refer to specialist
• if improved: continue for >1 month

Question 9

What is the surgical (last line) management for allergic rhinitis?

Answer 9

• Inferior turbinoplasty if permanent turbinate hypertrophy
• Relieves structural obstruction, but may not help rhinorrhoea
• Control, not cure. Turbinate hypertrophy can recur.