Allergic rhinitis causes swelling of nasal mucosa which is characterized by IGM mediated immune reaction. It is caused by a variety of indoor and outdoor factors which include animal dander, pollen, mites, and irritants like smoking.
It is an inflammatory condition of nasal mucosa due to their over sensitivity towards the allergic substances. The diagnosis of allergic rhinitis is usually based upon the signs and symptoms which may be mild, moderate, or severe.
Table of Contents
Types of Allergic Rhinitis
Allergic rhinitis is caused in the group of people who have hypersensitivity of the immune system to a particular type of allergen.
1- Seasonal Allergic rhinitis
It may be caused in a particular season which is called seasonal allergic rhinitis and it can occur mostly in spring, summer, and early autumn season.
2- Perennial allergic rhinitis
The Other kind of rhinitis which is perennial rhinitis occurs for the year and the people have the symptoms throughout the year. it is caused by inhaling the allergens to which the body’s immune system is overactive.
Allergic Rhinitis Causes
Allergic rhinitis is caused by over sensitization of the body’s immune system and the body’s immune system overreacts to environmental triggers. Such stimuli do not cause a problem for most of the people but the ones who have hypersensitivity for the immune system will come over sensitize and overreact to the allergens present in the air.
It is also called as ‘hay fever’ but it does not mean that it is a compulsion that you will have a fever.
What Causes Allergic Rhinitis?
The IgE antibody is produced in the people and is present inside the body. When the antigen combines with the antibody while exposure it produces swear immune reaction which causes the release of chemical mediators. These mediators cause the signs and symptoms of allergic rhinitis. The patient may suffer nasal congestion, sneezing, runny nose, and itching in eye, palate, and pharynx.
Acute or early phase reaction occurs immediately within 10 to 15 minutes after the exposure of the specific allergen and the patient experiences sneezing, rhinorrhea, nasal blockage, and bronchospasm. It occurs because a variety of active substances like histamine are released from the degranulation of mast cells.
Late phase reaction causes the symptoms in 2-8 hours after the exposure to the allergen and that without additional exposure. It occurs because of the infiltration of inflammatory cells which are eosinophils, monocytes, neutrophils, and CD4+ cells. It is that accumulation of all the cells occurs at the sight of deposition which causes swelling, congestion, and thick secretions inside the body.
When the continued exposure is given to the patient it results in acute phase symptoms which overlaps the late face symptoms and hence the patient suffers symptomatology of allergic.
1- Allergens / Pollutants
Allergic rhinitis can be caused by some allergens, dust, fumes, spore and pollutants. It may include
Outdoor Allergens
The outdoor allergens cause allergic rhinitis and they are present outside. When the patient breathes in that air it causes tiny particles of dust to go into the body which causes the release of IgE which forms the immune complexes and causes allergic rhinitis as a result.
Pollen.
it is a kind of outer allergen that is present most commonly in the spring season and the tiny particles of it can cause the symptoms of allergic rhinitis.
Spores
The spores disperse which are produced by fungi and mold can cause allergic rhinitis
Animal dander
It is a common problem that many people are allergic to the dander of animals and some are allergic to the animal’s fur their urine or saliva. It can Trigger the allergic rhinitis in the patient who is suffering from hypersensitivity.
Indoor Allergens
There are a variety of indoor allergens that are thought to produce the symptoms of allergic rhinitis and most of them are wood, dust, wheat flour, and latex.
The mites which are present in the bedding are thought to cause allergic rhinitis. It is very important for people to have hypersensitivity to the mites in beds so they need to clean their beddings before sleep and also keep their pillows and mattresses cleans. They should ask to get rid of these mites and allergy as a result.
Irritants
The returns like perfume, diesel exhaust, and cigarette smoke may cause the symptoms of rhinitis. It may be present throughout the year and sometimes will be aggravated during the periods of high triggering factors. The irritants act as nonallergic stimuli for causing rhinitis and it includes cigarettes most importantly. Other products inside the home which have a high and strong odor like cleansing products also cause irritant induced allergic rhinitis. The irritants if prevented can reduce the relapses of allergic rhinitis and the patient may suffer and will start to live the normal life again
2- Genetic Factors
Genetic factor tends to play an important role in symptomatology of allergic rhinitis and if any close family member has hay fever or any other allergy, the risk is very high and the person suffering from allergic rhinitis. If the parents of a child are suffering from allergic rhinitis there is a 50% chance that the child may also develop the disease.
3- Age and Gender
It is more common in boys as compared to girls but after puberty, the allergic rhinitis is more seen to be affecting females. The peak age at which allergic rhinitis can be caused is by 15 to 20 years of age although it can affect age groups.
4- Birth History
The people who are born in Spring and Seasons when there are high Pollens, they have a slightly higher risk to develop allergic rhinitis as compare the people were born in for having the low production of pollens
5- Passive Smoking
The people who do not smoke consider themselves as safe but if they are exposed to cigarette Smoke for longer period of time which means that if they are a passive smoker in the early stages of the life it increased the tendency of them having allergic rhinitis
6- Occupational or Environmental Allergies
Dust, smoke, perfume, and other occupational chemicals have a strong odor and it can cause allergic rhinitis. The chemical fumes of which are present in certain occupations which are you doing, they can also cause the symptoms of itching in the nose, nasal obstruction, sneezing, nasal discharge and itching in pharynx, larynx or eyes which results in allergic rhinitis.
Allergic Rhinitis Diagnosis
The diagnosis of allergic rhinitis is totally based upon the duration and the symptoms of the disease. The most common symptoms which are experienced by the person during the allergic rhinitis are sneezing which are 10 to 20 sneezes at a single time, nasal obstruction, watery nasal discharge, itching in the nose. They may also involve palate, pharynx, or eyes and the people may get respiratory difficulty due to spasm of the bronchus.
The symptoms change with the season and the symptoms may be severe at a particular season of the year and maybe mild at other. The duration of signs and symptoms is further divided into persistent, intermittent, and quality of disease is classified into mild, moderate, or severe. The new classification system which has been announced helps in the treatment of the patient and provides some guidelines for the purpose.
History and Clinical Examination
A detailed history and physical examination are required to diagnose the person suffering from allergic rhinitis and also give a lot of clues to diagnose the possible allergen which is causing allergic rhinitis in the patient. You should also rule out other causes of nasal obstruction and they should be excluded before we reach the final diagnosis of allergic rhinitis.
When you reach your health care provider, he may ask about the brief history of your symptoms which include:
- When did the symptoms start?
- Do you feel any symptoms aggravate in a particular season?
- Do you have a family history of allergic rhinitis?
- Do you have a family history of atopy?
- Is any of your siblings affected with the same condition?
After taking a complete history he may perform your general physical examination which involves the general appearance of yours and then he will move to a specific examination of your nose and other areas that are affected by allergic rhinitis.
The nasal signs can be seen by the presence of transverse nasal crease. It is also known as an allergic salute and it occurs due to constant rubbing of nose upwards which stimulate a salute and is accompanied by paleness and edema of the nose which may appear slightly bluish.
On the examination of eyes, the physician main rule out dark circles under the eyes which is also called allergic shiners and there is edema of eyelids and congestion in the eyes.
The tympanic membrane may be retracted on ear examination and it also gives a clue about allergic rhinitis.
Total and Differential Leukocyte Count
The first test which involves diagnosing allergic rhinitis is the total leukocyte count and differential leukocyte count. In the patient suffering from allergic rhinitis, there is an increased number of eosinophils but it is not a constant finding and may or may not rule out the disease.
Nasal Smear
The doctor may ask you to get the nasal smear which includes getting a sample of your discharge from nose and then diagnosing get in the laboratory. It shows a large number of eosinophils. The nasal smears are to be taken when the disease is clinically active after the nasal challenge test. Sometimes the increased number of eosinophils is also seen in nonallergic rhinitis which is called Non-Allergic Rhinitis with Eosinophilia Syndrome (NARES).
Skin Tests (Skin Prick Test)
Skin tests help to identify the specific kind of allergen which is triggering the disease in the person. They are usually pricked test, scratch test, and the intradermal test. The skin prick test is one of the best methods which helps to demonstrate the kind of allergen. It includes placing a drop of concentrated allergen solution in the superior surface of the forum or back and then a fine needle is pricked to the dermis through that drop.
It includes the allergen into the dermis and a positive reaction is manifested by the formation of wheal of reaction which is central and its surrounds zone of redness within 10 to 15 minutes. A control test is performed simultaneously with histamine and the diluent is used in the allergen solution.
Skin Tests (Specific IgE Measurements)
This test is used to find out the specific allergen and there is a good correlation between this test and IgE specific measurements. The false-positive and false negative test can occur as a result of this and there is a recommendation that both the test needs to be correlated with the clinical signs and symptoms, the patient is suffering from.
Radioallergosorbent Test (Rast)
This test is a kind of in vitro test and admires the IgE antibody concentration which is present in the patient serum. The IgE antibody is produced as a result of allergen which triggered the production of it. As a result, the amount of IgE antibody is increased which causes the release of basophils, mast cells and releases mediators which are prostaglandins, leukotrienes, tumor necrosis factor Alpha, Thromboxane A. Radioactive allergy test helps to reveal the concentration effectively.
Nasal Provocation Test
It is a crude method that Triggers the allergy in the patient by placing a small amount of an allergen at the end of a toothpick or earbud and introducing the allergen to the patient’s nasal mucosa. The patient is asked to sniff into each nose and you need to observe if there are any allergy symptoms the patient may suffer. It is not a good idea to check the patient for allergic rhinitis because he might suffer signs and symptoms of the disease. Many sophisticated and less painful methods and are available to diagnose allergic rhinitis. Nasal smear, skin prick test, and nasal provocation tests are the test available easily for allergic rhinitis diagnosis.
ALLERGIC RHINITIS TREATMENT
The treatment of allergic rhinitis involves three basic factors which the patient needs to be very careful about. Some treatment options simply reduce the symptoms of the patient while other treatment options remove the disease from the core and the patient is able to spend his normal life for the rest of the years. There are three treatment options was the patient can be treated with.
- Avoidance of allergen
- Treatment with drugs
- Immunotherapy
- Step Care Approach
Avoidance of Allergen
It is one of the best kinds of treatment for allergic rhinitis and it involves the removal of triggering factors for allergic rhinitis. You have to do the removal of a kind of factor from the house, change the casing of mattress and pillow with some kind of plastic sheet, there needs to be a change in the occupation if the triggering factors are found in the occupational places.
Sometimes the patient has an allergy to a particular food and that food needs to be eliminated from the diet of the patient so as to treat him in the best possible way. The patient needs to be guided about the elimination of allergen and avoiding the triggering factors as much as you can because it otherwise increase the symptoms of allergic rhinitis and the treatment becomes difficult. The flares of allergic rhinitis can be prevented by avoiding a certain triggering factor and it aids the allergic rhinitis treatment.
Treatment with the Drugs
The treatment with the drugs helps to relieve the symptoms with which the patient presents with.
Antihistamines
Antihistamines are really effective in controlling the watery nasal discharge, sneezing, and nasal itching. There is a common side effect that all antihistamines have and it includes sleepiness more than the other side effects. The type of antihistamines and the dose of antihistamines need to be individualized. If one kind of antihistamine is not effective in a patient, then another kind of Antihistamine is to be added to relieve the symptoms.
Sympathomimetic drugs (topical/oral)
These drugs can be given topically orally. They are helpful in constricting the blood vessels which reduce the nasal congestion and sneezing as a result. They can also be given with antihistamines which will cause the stimulation of the central nervous system and will counter the effect of sleepiness produced by antihistamines. Phenylephrine and Pseudoephedrine are given in combination with antihistamine and given to the patient orally.
Corticosteroids
Oral corticosteroids are really very effective in controlling the Symptoms and Signs of allergic rhinitis but they are usually Limited for the acute episodes with the patient presents with. They are also given for the episode of allergic rhinitis which cannot be controlled by any other drugs. The corticosteroids are limited for the cases which are resistant to other treatment options because they have a lot of systemic side effects.
Sodium cromoglycate
It helps in the stabilization of mast cells and prevents them from degranulation despite of the fact of formation of the IgE antibody Complex. It inhibits the release of mediators of inflammation and is used in both seasonal and perennial kind of allergic rhinitis. it is used as nasal drops or nasal spray or as a nasal powder. It inhibits the release of mediators despite the formation of the antigen-antibody complex and prevents the inflammatory symptoms of allergic rhinitis.
Anticholinergics
They are really helpful to block the rhinorrhea. Ipratropium Bromide is used to control rhinorrhea as a topical therapy. it is used as a nasal spray and there are no systemic side effects of anticholinergic drugs.
Leukotriene receptor antagonistic
They block the receptors of Leukotriene and are very well tolerated by a lot of patients. the kind of drug which can be given to the patient for blocking the leukotriene receptors includes montelukast, zafirlukast, and pranlukast. They are tolerated by patients very well and they have very little side effects.
Anti IgE
It causes a reduced level of antibodies and has some anti-inflammatory effects. There are a variety of IgE drugs available and Omalizumab is such a kind of it. It is usually given to the patients having asthma with allergic rhinitis and are above 12 years of age.
Immunotherapy
Immunotherapy is a therapy which desensitizes or hypersensitize the immune system and is used when other kinds of drug treatment options fail. It is also used to in the drugs for controlling a variety of side effects. The drug is given gradually and is increased for the patient until the maintenance dose of the drug is reached.
The immunotherapy suppresses the formation of IgE and also raises the other kind of antibody which is IgG. Immunotherapy has to be continued for many years until the significant improvement and the symptoms are noticed to be lessened by the patients.
It is discontinued or interrupted if treatment for 3 years of immunosuppression gives no benefit to the signs and symptoms experienced by the patient.
The immunotherapy given to the patient is subcutaneous but recently sublingual and nasal routes are also being used to treat the patient. The sublingual enable routes require the drug 10 to 80 times greater than used by a subcutaneous route.
Step Care Approach
Mild disease
Oral antihistamines or intranasal cromoglycate sodium is usually recommended for mild disease.
Moderate disease
when the patient experience the symptoms of moderate disease variety for persistent disease, internal corticosteroids can be used as monotherapy.
Severe disease
For severe symptoms, the combination therapy with oral nonsedating antihistamines and intranasal steroid is usually recommended.
Severe and persistent disease
Severe and persistent symptoms of allergic rhinitis despite the treatment with the above-given drugs recommends the use of oral steroids and immunotherapy.
If the patient suffers the nasal obstruction and congestion for a longer period of time, a short course of a nasal decongestant can be given to the patient. It is usually combined with antihistamines.
Allergic Rhinitis Complications
Allergic rhinitis causes you to have plenty of complication and if you are already suffering from this condition it is the high probability that you can affect your health further and develop plenty of other problems as well. The most common complications which it causes are nasal stuffiness, difficulty in concentrating, Eustachian tube defects, inflammation of nasal sinuses, and it sometimes exacerbates the symptoms of asthma and other respiratory tract infections.
Acute and Chronic Sinusitis
It is the inflammation of nasal mucosa and it usually occurs 2 to 4 weeks after allergic rhinitis and may last for weeks or months. The patient may present with nasal obstruction, nasal discharge which is common, anterior or posterior discharge in the form of postnasal drip, there is a sense of pain or pressure on the face, the sense of smell is altered and it is referred as anosmia or hyposmia.
The patient may present with cough, fever, bad breath, fatigue, inflammation of the pharynx, headache, dental pain, and ear fullness. The treatment strategies involve giving the patient antibiotics and pain killers. The antibiotics can really decrease the course of the disease but sometimes they can worsen the patient’s situation. Nasal saline irrigation is given to thin the mucus to give the symptomatic relief to nasal obstruction.
Otitis Media or Middle Ear Infections
The otitis media is referred to the information of Middle ear infection and occurs due to some pathogenic organisms and it is more common in infants and children of low social class. After allergic rhinitis, the bacteria or viral infections may go to of respiratory tract and when the organism invades the middle ear, the patient suffers from otitis media. The discharge from the ear is usually what the patient suffers, difficulty in hearing, tinnitus, altered voice. The earache is relieved when the puss from the year is evacuated.
The patient is given antibacterial therapy with fever and earache. The antibiotic treatment is given for 10 days until the eardrum retains its normal appearance and hearing is stable. if the therapy is not completed adequately the hearing loss may result.
Sleep Apnea
It is one of the worst complications of allergic rhinitis and it means no breathing at all. It is caused when the patient is asleep and it leads to frequent arousals when the patient is in pain and unable to breathe at all which causes the fragmentation of sleep, daytime sleepiness, and other manifestations of the disease.
Sometimes the retention of carbon dioxide in the body will lead to congestive cardiac failure and hypoxia leading to cardiac arrhythmias or sometimes sudden cardiac death. The patient is advised to change the lifestyle and he should be sleeping on the side and over the spine position because it might aggravate the sleep apnea. The surgery is indicated for failed medical therapy.
Mouth Breathing
Allergic rhinitis causes adenoid formation sometimes which causes obstruction to the breathing from the nose and the patient is compelled to breathe from the mouth and is referred to as mouth breather. The adenoid causes nasal obstruction and difficulty in breathing and the breathing process from the mouth is really easy. It should be treated by adenoidectomy And counseling the patient.
Eustachian Tube Defects
The eustachian tube is a small tube that equalizes the pressure by draining fluid from the middle ear. The Eustachian tube becomes clogged and it occurs as a result of allergic rhinitis. The defect may last up to a few days or weeks but sometimes it may be present for a longer period of time. The patient feels ear pain, feeling of ear fullness, difficulty in sleeping and dizziness, tinnitus, or ringing sound in the ear. The allergic rhinitis sometimes can cause retraction of the real drum due to Eustachian tube defects and the eardrum is sucked back into the Eustachian tube.
Nasal Polyps
The nasal polyps are the masses present inside the nostrils due to edema of the nasal mucosa. It usually has a stock and around the head. This type of complication of allergic rhinitis is most commonly seen in children and young adults and usually, the nasal polyps are single and unilateral in nature. The presenting sign and symptom of the patient after allergic rhinitis is single-sided nasal obstruction.
The patient may feel the voice becoming thick and dull due to hyponasality, the nasal discharge can be seen on one or both sides of the nose. Sometimes a polyp may grow posterior part of the nose and hang down behind the soft palate and is present in the oropharynx. A detailed examination of the nose with an endoscope is required to reveal the polyps which are held in anterior or posterior in the nasal cavity.
Glue Ear
It is referred to as the accumulation of no-pus discharge in the Middle ear. The fluid is thick and viscous but sometimes it may be thin and watery. It usually occurs due to the malfunctioning of the Eustachian tube secondarily to allergic rhinitis.
The patient may present with hearing loss, delayed and defective speech, and mild headache. when the tympanic membrane is seen with the otoscope, it is retracted, dull, and opaque and air Bubbles may be seen inside the fluid. The patient is given plenty of antibiotics, nasal decongestants, and anti-allergic sprays so as to deal with glue ear complications of allergic rhinitis.
Allergic rhinitis causes plenty of complications which include nasal polyps, glue ear, middle ear infections, Eustachian tube defects, acute or chronic sinusitis, sleep apnea, and mouth breathing. It can also Trigger respiratory tract infections and hearing problems if they remain untreated.
Allergic Rhinitis Prevention
The prevention of allergic rhinitis is to avoid the allergen which usually causes allergic rhinitis. This procedure is really difficult because some allergens are not visible to the naked eye like microbes and mites which are present in the buildings and such organisms can even breed in the cleanest places and it is really hard to find them out. The pets can really be avoided but it again becomes difficult while you are going to a family gathering of friends. There are plenty of preventions you can take to avoid this disease and some of them are given below.
Identify the specific allergen
The allergens may be easy to identify in some people because the symptoms develop in a particular season or exposure to that or any other animal. The allergens in other people who are allergic to trees, grass, animal’s fur, and molds may be difficult to identify because they cannot be seen by the naked eye and it becomes very difficult for the people to assess the allergen.
Prevention of allergens
The exposure to the particular allergen if you know Trigger your disease should be prevented. The home and the workplace is the basic area where we are exposed to air it so it is important to prevent all the triggers to prevent allergic rhinitis.
Cleansing the bed mattress and pillows
Dust mites are minute organisms that are present in bedding, sofas, pillows, and carpets. They are not really easy to see with the naked eye and they absorb all the moisture from the atmosphere and feed themselves in the human environment. The mite allergy can be prevented by frequently washing the pillows, mattresses, and comforters because these are the places where the mites may be present.
The tightly woven fabrics should be prevented because they cause the passage of mites inside them and the air can not cross which causes entrapment of mites and disease occurs as a result. You should try to wash all your blankets, sheets in the hot water and with some antibacterial solution inside and then dry it in an electric dryer.
Control humidity
The human environment is where the mites and other microbes are more prone to get so it is very important that you control the humidity and control the temperature of your home. The monitoring devices for humidity can be purchased because they will allow you to accurately know the humidity level of your home.
Cover yourself
Whenever you go outside try to protect yourself and wear a hat or mask and gloves on the hands and frequently wash your hands, face, and nose. When you get back to the home, try to change your clothes because you might have some allergens stick inside your shirt which you might not look even, so change your clothes frequently. Try to bath twice a day so as to avoid any kind of allergen present in your bedding or house and if it happens to touch your body surface, it does not enter your nostrils and cause disease.
Animal dander
Some people are allergic to animal dander which is made up of dead skin cells which are shattered by the animals constantly. The hairy animals have more capability to cause allergic rhinitis in susceptible individuals as compared to less hairy animals.
If the person is particularly allergic to the pet he should remove the pet from the home and if the removing is not possible, he should change his own place because if the trigger is present he will constantly be suffering the symptoms of allergic rhinitis. When the pet is removed from the home then it is very crucial to clean the home effectively change the coverings and casing of the home to clean all the allergens.
Pesticides control
Pesticides should be used to kill the pests because they are not seen with the naked eye but can cause allergic rhinitis in susceptible individuals. Try to keep the food and the trash in covered areas and also clean all the food traps from the home as they are the hub for the growth of rodents. Use pesticides when needed to control their growth.
Immunotherapy or immune system boosters.
It is very crucial to have a boost to the immune system which will help you to fight the allergic rhinitis and prevent it. You need to get eating a healthy diet and do exercise regularly. It is recommended that you exercise every day 30 minutes which will keep you fit and healthy and this will strengthen your immune system as a result and you might not catch allergic rhinitis.
Air filters
The air filter devices can be used to reduce the allergens which are present indoors. These units are present to keep inside the room or sometimes they are worn by the individual. The air filters usually do not remove the dust mite allergy because they are heavy so show the air filters are not known to remove all kinds of allergens. they can effectively remove the pollen because they are light as well as animal dander because they remain Airborne.
Meeting with allergist
Meet with your allergist who might tell you about the possible treatment of your allergic rhinitis and will let you know about certain ways by which you can prevent this disease. He may give you some specific recommendations for the prevention of allergic rhinitis which is very much crucial.
The basic allergic rhinitis prevention is to avoid triggering factors and allergens. Try to identify your allergens, avoid them, and if symptoms appear talk to your allergist. He may recommend your specific treatment or prevention ideas for this disease.
HP Thoughts: Allergic rhinitis is a real pain in your nasal cavities. What if gets worse and leads to a nosebleed? Read to learn more — EPISTAXIS ICD 10.
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