«Allergic Rhinitis By: Raymond Lengel, FNP, MSN, RN Purpose: Provide an overview of allergic rhinitis including its causes, signs and symptoms and ...»
By: Raymond Lengel, FNP, MSN, RN
Purpose: Provide an overview of allergic rhinitis including its causes, signs and symptoms
and treatment strategies.
• List three causes of allergic rhinitis
• List five signs and symptoms of allergic rhinitis
• Discuss diagnostic testing options for allergic rhinitis
• Discuss five non-pharmacological interventions in the treatment of allergic rhinitis
• Discuss the pharmacological treatment options in the management of allergic rhinitis Allergies affect the lives of 40 - 50 million Americans (1) and 24 percent of Europeans (2).
Individuals affected with allergies can have a significant reduction in quality of life as allergies are associated with sinus infections, otitis media, sleep apnea, hearing impairment, aggravation of underlying asthma, reduced cognitive functioning, learning impairment and nasal polyps. Children with allergies are affected by impaired learning, reduced social interaction and mental health problems (3). Not only does the disease reduce quality of life, but some of the treatments of allergic rhinitis can affect quality of life.
Allergic rhinitis is highly correlated with asthma and atopic dermatitis. Eighty percent of those who have asthma and 80 percent who have atopic dermatitis also suffer from allergic rhinitis (3).
Allergies are a very common problem (4).
• 25% of individuals suffer from allergies at some point in their life
• More than 50% have the condition for greater than 11 years
• Slightly less than 50% of those with allergies report symptoms for more than 2 seasons per year
• In adults, men and women are equally affected
• More women report persistent allergies than men
• In children, more boys are affected than girls
• The average age of onset is 8-11 years old Pathophysiology The mucus membranes of the eyes, nose, ears and pharynx become inflamed in allergic rhinitis. In susceptible individuals, allergens lead to the production of an immunoglobulin E (IgE). The IgE attaches to the surface of the mast cell which cause the release of many different mediators. Common mediators involved in allergic rhinitis include prostaglandins, histamine, bradykinin and leukotrienes.
Prostaglandins are released by many different body tissues and they increase the action of histamine. Prostaglandins are released at the site of inflammation and are also involved in pain and are linked to body temperature.
Histamine is contained in some white blood cells and mast cells and are released during inflammation. Histamine is involved in vasodilation, smooth muscle spasm and vascular permeability.
Leukotrienes are released by white blood cells and are responsible for vasodilation, chemotaxis and contraction of bronchial muscle.
Bradykinin is also involved in the allergic response. It is involved in vasodilation, vascular permeability and pain transmission.
Some of the pharmacological therapies used in the management of allergic rhinitis are targeted at these mediators.
Many factors increase the risk of allergies. Common risk factors include:
• Maternal smoking
• Living in areas of high pollution
• Higher socioeconomic status
• Exposure to indoor allergens as a child
• Early introduction of food or formula as an infant
• Non-Caucasian race
• A family history of allergies, asthma and eczema
• Personal history of asthma and/or eczema Signs and Symptoms Allergies can present in various ways. Each individual may have different symptoms.
Common symptoms of allergies include:
The classical presentation of allergic rhinitis is clear rhinorrhea, sneezing, watery, red eyes and itching in the eyes, nose and throat. Some individuals will complain of mainly nasal congestion. Those who suffer from persistent one-sided nasal congestion should be evaluated for the possibility of a deviated septum, nasal polyp or foreign body.
Patients will also complain of being tired. About 50% of those with allergic rhinitis do not feel rested in the morning (2). It is unclear how much of this is related to the disease and how much is related to the medications used to treat the disease.
Those who suffer from persistent disease report more problems with feeling tired than those with intermittent disease. In addition, those with persistent disease are more likely to complain of feeling irritable, worn out or frustrated (2, 4).
Upon physical exam a number a factors may be noted. When looking in the nose the mucosa may be pale and boggy with enlarged nasal turbinates and thin secretions. Thick discharge does not rule out allergies. Blood may be noticed in the nose from a combination of a dry nose and frequent rubbing of the nose or nose picking. The nose may have a crease due to frequent rubbing of the nose. This suggests that the patient has been rubbing his nose because of itching. The throat may show enlarged tonsils and a cobblestone appearance to the back of the throat. Nasal polyps could be seen. These will look like firm gray masses and may be attached by a stalk.
The eyes can appear red with watery discharge. The conjunctiva may have a cobblestone appearance. There might be a lower eyelid crease called Dennie-Morgan lines. Allergic shiners or periobital edema could be noted around the eyes. Allergic shiners are related to congestion in the nasal passages that affects blood flow.
Fluid behind the ears might be noticed, which may be suggested by seeing fluid or bubbles behind the tympanic membrane, reduced tympanic membrane mobility or a bulging tympanic membrane.
A physical exam should also listen to the lungs and evaluate the skin to assess for any evidence of asthma or eczema, which often accompany allergic rhinitis.
Key questions Getting a good history will help in the management of allergic rhinitis. Below are a list of questions that can significantly help the clinician understand the allergies and how best to treat them
• When did the symptoms start?
• How long have they been present?
• When are symptoms present (is there a seasonal pattern or do certain environments
• How often do the symptoms occur?
• Are symptoms present all day or do they get better at some points during the day?
• Has there been any change in the environment that may be contributing to the symptoms (construction in the home/just started cutting the grass)?
• Which symptoms are most bothersome? This may help determine which treatment is
Allergy Triggers Certain factors trigger allergies. Figuring out what triggers symptoms will improve the ability to manage allergies. Knowing what causes the symptoms helps patients know how to avoid that trigger. Sometimes it is not that easy. When one is allergic to grass pollen in the spring, the only way to completely avoid the allergen is to stay inside. This is not a practical strategy.
Those who are affected by allergens that cannot be avoided may need medications to control their symptoms. Common allergens to consider includes: mold spores, animals, grass, smoke, pollution and outdoor pollens.
A recent survey suggested that plants, flowers, house dust mites, animals and tobacco smoke are the top allergens. Other contributors include: molds, foods, feathers and perfumes (2) Utilization of the allergy chart (Table 1) will help patients get a handle on their allergies.
Recording the severity of the symptoms at a given time and what the patient was doing at that time can help determine what triggers the allergy symptoms. Filling out the chart for a couple of days and then studying the chart will help the patient get a handle on patterns of symptoms. Have the patients consider the questions listed above (under the key questions section) in regard to the allergy chart. For example, if allergy symptoms are most severe when going outside to the local park, this may indicate that there are allergies to grass or tree pollens.
The second to last column is titled medications. Medications taken are recorded here to help provide some explanation of how effective medications are at managing symptoms. For example, if symptoms are much improved for 4 hours after taking Benadryl, this indicates that
0 - none; 1 - mild; 2 - moderate; 3 severe; 4 - unbearable Classification of allergies One method of classification of allergies is to break them down into perennial and seasonal.
• Perennial allergies are symptoms that occur throughout the year. They are usually brought on by a specific allergen or allergens in the home such as pets, mold, dust mites, cockroaches or rodents.
• Seasonal allergies take place during a specific time to a specific allergen. Tree pollen allergies are more common in the early spring and grass pollens are more common in the late spring and throughout summer. Weed pollens cause most problems in the late summer and into the fall. Ragweed allergy commonly occurs in the fall. Dry, sunny and windy days are often associated with the highest pollen counts and with the worst symptoms. Outdoor molds are another source of allergic symptoms and can be agitated by gardening or digging.
• Some medications can induce allergic like symptoms including: aspirin, ibuprofen, estrogen and birth control pills.
Another way of classifying allergies is by intermittent versus persistent and mild versus moderate/severe.
• Intermittent allergies are symptoms less than four days a week or symptoms lasting
• Mild symptoms do not interfere with sleep, daily activities, work or school and do not cause any troublesome symptoms.
• Moderate/severe symptoms are associated with at least one of the following: abnormal sleep, troublesome symptoms, problems at work or school or impairment in daily
• Viral illness. The common cold is often confused with allergies. While they have many similar symptoms, viral illnesses usually present with an abrupt onset of upper respiratory symptoms. Viral illnesses are often associated with a low-grade fever.
• Foreign body. The younger child with one-sided symptoms is more at risk for having an
• Sinus infection. Prolonged symptoms of nasal congestion may be a sinus infection.
Rarely are sinus infections associated with sneezing and watery eyes.
• Non-allergic rhinitis. This occurs when there is exposure to irritants or weather changes. There is less itching and more postnasal drip.
• Rhinitis medicamentosa occurs with prolonged use of topical nasal decongestants.
• Hormonal rhinitis is often seen in pregnancy or hypothyroidism.
Testing Usually allergies are diagnosed on history and physical exam, but in some cases testing can be employed. Two tests are commonly used for diagnosing allergy symptoms. These tests are used to detect allergen-specific IgE. The most common test is allergy skin testing.
This involves the health care provider pricking the skin and introducing a small amount of allergen. Many allergenic extracts are available to the clinician. If the skin reacts to the allergen, than there is an allergy; if there is no reaction, there is no allergy. The test is quick, inexpensive and sensitive.
In this test the antigen binds to IgE of the mast cell on the skin. In a sensitized individual, a wheel and flare reaction, which is associated with itching, is noticed in 15-20 minutes. A bigger reaction is associated with a more severe allergy. Intradermal testing – which is much more sensitive than percutaneous testing – can be done by introducing the allergen into the dermis with a percutaneous needle.
The radioallergosorbent test (RAST) examines the blood to determine serum allergenspecific IgE levels. It is less helpful than skin tests, as it is not as sensitive, more expensive and limited in what it can test for. It tests for dust mites, pollens, molds and pet dander but less helpful for food, drugs or venom. Skin testing is preferred to RAST because skin testing is more sensitive, less expensive and tests for more allergens.
An advantage of the RAST test is that its results will not be affected by skin rashes or if the patient has taken antihistamines.
Other testing is sometimes employed in those with allergies. These may include:
• Blood tests for total serum IgE and total blood eosinophils can be used as part of the evaluation of allergies. These tests are not specific or sensitive and therefore not used as standalone tests in allergic rhinitis.
• Sinus films and CT scans can be used in the evaluation of the sinus cavities. These tests are commonly used to diagnose sinus infections. CT is a more sensitive test for sinus infection and can also help pick up septal deviation, nasal polyps and swelling of
• Magnetic resonance imaging can also be used in the evaluation of sinus infection but is not as sensitive as CT scanning. It is more helpful in finding cancer of the upper
Treatment There are three primary treatment categories for allergies.
1. Environmental control
3. Immunotherapy Knowing the cause of the allergies allows more effective treatment of the allergies. This is an argument in favor of allergy testing. Those who have had their allergies tested know what aggravates them and can avoid those allergens. Lifestyle interventions, which include allergy avoidance and environmental control are a mainstay in allergic rhinitis management.
The next section will provide some tips for managing allergic rhinitis utilizing environmental control and allergy avoidance. Tips will be provided for those who suffer from indoor and outdoor allergies.