Allergic rhinosinusitis

Question 1

Define allergic rhinitis

Answer 1

IgE-mediated inflammatory disorder of the nose which occurs when the nasal mucosa becomes exposed and sensitized to allergens

Question 2

Classification of allergic rhinitis

Answer 2

intermittent vs persistent
- Intermittent = < 4 days a week or <4 consecutive weeks, typically due to animal dander
- Persistent = >4 days a week AND >4 4 consecutive weeks, typically due to house dust mites
mild vs severe
- Severe = troublesome and impacting on sleep and ADLs
seasonal vs perennial
- Seasonal = same time each year in response to a seasonal allergen e.g. grass and tree pollen
- Perennial = throughout the year, typically due to house dust mites and animal dander

Question 3

Aetiology of allergic rhinitis

Answer 3

Nasal mucosa becomes exposed and sensitized to allergens → histamine and inflammatory mediator release → sneezing, nasal itching, discharge, congestion

Allergens:
- Grass, tree, weed pollens
- Moulds e.g. alternaria, cladosporium, aspergillus
- Animal dander e.g. cat, dog hair
- Occupational e.g. latex gloves, chlorine, flour, wood dust, lab animals

Question 4

Symptoms of allergic rhinitis

Answer 4

Coryza
Conjunctivitis
Chronically blocked nose
Sleep disturbance, impaired daytime behaviour/concentration

Question 5

Signs of allergic rhinitis on examination

Answer 5

General
- Nasal intonation
- Allergic shiners: darkened eye shadow under lower eyelids due to chronic congestion
- Erythematous conjunctiva with watering eyes
- Other signs of allergy: urticaria, facial swelling, eczema
Examine nose:
- Rhinorrhoea
- Depressed or widened nasal bridge,
- Allergic salute from rubbing an itchy nose (Nasal itching)
- Mouth breathing (may have an obstructed nasal airway from rhinitis)
- Mucosal swelling, grey discolouration
- Hypertrophic nasal turbinates: soft pink swelling from the lateral nasal wall
- Nasal polyps: soft yellow swellings between septum and turbinates
- Deviated nasal septum
- ?foreign bodies

Question 6

Investigations for allergic rhinitis

Answer 6

Clinical diagnosis

Skin prick → RAST testing
Trial antihistamines and/or intranasal steroids

Question 7

Management for allergic rhinitis

Answer 7

Avoid causative allergen e.g. grass, dust mites

Mild-moderate:
1st line: PRN oral antihistamine (cetirizine, loratadine) or PRN intranasal antihistamine (azelastine)
2nd line: PRN intranasal sodium cromoglicate

Moderate-severe
Nasal blockage / polyps → intranasal corticosteroid (beclomethasone), nasal irrigation
Sneezing / discharge → intranasal corticosteroid or oral antihistamine

Specific allergen immunotherapy (SCIT): Solutions of an allergic allergen are injected SC or sublingually on a regular basis for 3-5 years