allergic rhinitis

Question 1

what is it?

Answer 1

Allergic rhinitis is an IgE-mediated inflammatory disorder of the nosewhich occurswhen the nasal mucosa becomes exposed and sensitised to allergens

this triggers the release of histamine and other inflammatory mediators, which act on cells, nerve endings and blood vessels to cause sneezing, nasal itching, discharge and congestion.

(type 1 sensitivity reaction)

Question 2

how can allergic rhinitis be classified?

Answer 2

According to timing, frequency and persistent of symptoms

May be triggered by many different allergens

• Seasonal e.g hay fever if caused by grass and tree pollen
• Perenial if occurs throughout the year e.g house dust mites and animal dander
• Intermittent e.g <4 days a week for >4 weeks

Also severity

• Mild symptoms dont really impact life
• Moderate or severe symptoms are troublesome and impacting on daily activities or sleep

Question 3

what is occupational allergic rhinits?

Answer 3

Symptoms in a previously unaffected person, due to exposure to allergens in the work environment, for example, flour allergy in a baker, or bleaching agents andhair dyes in a hairdresser

Question 4

what are some common causes of allergic rhinitis?

Answer 4

• House dust mites
• Grass, tree and weed pollens
• Moulds
• Animal dander
• Occupational e.g flour and dyes

Question 5

what are the complications of allergic rhinitis?

Answer 5

• Impaired QoL, affecting work, home and social life, especially in peak pollen season
• risk factor for asthma development
• Sinusitis and nasal polyps, as swelling of the nasal mucosa leads to obstruction of the drainage of the sinuses
• Oral allergy syndrome

Question 6

what are the typical clinical features of allergic rhinitis?

Answer 6

• Sneezing
• nasal itching
• Rhinorrhoea
• Nasal congestion
• Bilateral symptoms within minutes following allergen exposure
• Post nasal drip
• Itching of palate
• itchy throat
• Cough
• FH of atopy (asthma, eczema or allergic rhinitis)

Question 7

what can be observed in a patient with allergic rhinitis?

Answer 7

• Nasal intonation of the voice
• Darkened eye shadows under lower eyelid due to chronic congestion (allergic shiners)
• Horizontal nasal crease under dorsum of nose
• Deviated or perforated nasal septum, depressed or widened nasal bridge
• Nasal mucosa swelling and greyish discolouration
• Nasal polyps (rare in
  children)
• Purulent nasal discharge

Question 8

what are some alternative causes for rhinitis?

Answer 8

• infective rhinitis

- non allergic rhinitis

Question 9

what is rhinitis?

Answer 9

inflammation of the mucus lining of the nose

Question 10

what self management strategies can be advised?

Answer 10

• Information sources on hay fever and patient leaflets should be offered. Also can suggest looking at patient.info and NHS website.
• Advise consideration of use of nasal irrigation with saline
• Provide advise on allergen avoidance techniques e.g avoid walking in grassy open spaces, especially during early morning and early evening. Avoid drying washing outdoors, close windows in cars and buildings, shower or wash hair following high pollen exposure.
• If dust mite allergy, after allergy testing, use synthetic pillows, wash bedding once a week at high temperature, wooden floors, blinds instead of curtains
• Avoid animal or restrict animal area

Question 11

what drug treatments can be recommended?

Answer 11

mild to moderate intermittent, or mild persistent symptoms, can suggest as needed use of intranasal antihistamines first line or non sedating oral antihistamines depending on age and personal preference (NB combined use isn’t recommended)

if symptoms are moderate to severe persistent, or initial treatment hasn’t work, can give regular intranasal corticosteroid to be used during periods of allergen exposure, where onset of action is 6-8hrs after first dose and max effects may not be seen until after 2 weeks.

advise person to continue treatment until no longer likely to be exposed to suspected allergen

if after review 2-4 weeks later symptoms persist, will need referral.

Question 12

what are some red flag features?

Answer 12

unilateral symptoms, blood-stained nasal discharge, recurrent epistaxis, or nasal pain

arrange an urgent two-week wait referral to ENT.

Question 13

what is allergy testing and when can be be useful?

Answer 13

Allergy testing may involve skin prick testing or measuring the levels of serum-specific immunoglobulin (Ig) E to allergens such as house dust mites, pollen, and animal dander (radioallergosorbent test [RAST]).

can help differentiate between allergic and non allergic rhinitis.

Question 14

what is atopy?

Answer 14

genetic predisposition to produce IgE after
antigen exposure. This leads to a tendency toward
developing hypersensitivity reactions, especially allergic
rhinitis, eczema, and asthma (atopic triad).

Question 15

what is the skin patch test?

Answer 15

Useful for contact dermatitis. Around 30-40 allergens are placed on the back. Irritants may also be tested for. The patches
are removed 48 hours later with the results being read by a dermatologist after a further 48 hour

Question 16

what is the skin prick test?

Answer 16

Drops of diluted allergen are placed on the skin after which the skin is pierced using a needle. A large number of allergens
can be tested in one session.

Normally includes a histamine (positive) and sterile water (negative) control. A wheal will
typically develop if a patient has an allergy. Can be interpreted after 15 minutes

Useful for food allergies and also pollen

Question 17

what is imunotherapy?

Answer 17

2nd line:

controlled exposure to gradually increasing doses of the allergen in order to hyposensitise the IgE response (imunotherapy)

Question 18

what tests can be done for allergen diagnosis?

Answer 18

• Skin Patch Test
• Skin Prick Test
• RAST Test