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Allergic rhinitis

Essentials

  • The connection and interrelatedness between rhinitis and asthma must be borne in mind, and whenever possible the investigations and treatment should include both conditions.
  • Instead of trying to avoid allergens, the patient’s tolerance to allergens should be enhanced in different ways. The avoidance of allergens is needed when the symptoms are severe, but as soon as the situation has calmed down, methods that strengthen tolerance should preferably be applied.
  • Investigations performed by an ENT specialist are required if the symptoms are severe and unresponsive to treatment, if allergen-specific immunotherapy (desensitisation) is considered or if there is a suspicion of occupational rhinitis.

Signs and symptoms

  • See table T1

Table 1. Signs and symptoms in the different forms of hypersensitivity rhinitis
Allergic rhinitis Non-allergic rhinitis
Eosinophilic Non-eosinophilic (vasomotor)
Genetic predisposition Yes (tendency for atopy) No No
Age at onset Childhood Middle-age (30–50 yrs) Middle-age (often > 40 yrs)
Occurrence of symptoms Seasonal, may also be perennial Perennial Perennial
Asthma In about 20% In 30–40% Rare
Polyps Occasionally Often Rarely
Prick/RAST tests positive Yes No No
Secretory eosinophilia Often In all patients at some stage (diagnostic criterion) No

Epidemiology

  • Atopic IgE-mediated allergic rhinitis affects about 25–30% of the adult population in Western Europe. In the majority of cases rhinitis is caused by pollen allergy (deciduous trees, grasses, mugwort). Other common causes of allergic rhinitis include animal and cereal allergens and other organic dusts, often from occupational exposure. Additionally, about 10% of adults have chronic non-allergic hypersensitivity rhinitis.

Investigations and findings

  • Carefully compiled patient history
    • Previous history of atopy
    • The character of symptoms (seasonal or all year round; intermittent or persistent according to ARIA classification, picture (ARIA-classification))
    • Symptoms (clear nasal secretions, stuffy and itching nose, rhinorrhoea, sneezing)
      • About 70% of patients with allergic rhinitis have concurrent conjunctival symptoms in the eyes (redness, tearing, itching).
    • Associated diseases (sinusitis, otitis media, asthma)
    • Exposure data (particularly if an occupational disease is suspected)
  • Rhinoscopy, preferably using a headlight and topical nasal decongestant (a complete ENT examination is indicated during the first visit), if the patient complains of nasal congestion.
    • The aim is to identify nasal polyps (Nasal polyps).
    • Livid pale grey or bluish mucous membranes (suggestive of an allergic reaction, but other types of findings do not exclude allergy)
    • Secretions may vary from clear watery to mucous.
  • An ultrasound examination may be performed to check the presence of secretions in the maxillary sinuses if the symptoms suggest acute bacterial rhinosinusitis.
  • An x-ray of the paranasal sinuses is helpful in the evaluation of chronic sinusitis, particularly if the symptoms have persisted for a long time (months to years).
    • In children, x-ray studies should only be carried out after careful consideration within specialized health care and preferably by using cone-beam CT of the paranasal sinuses.
  • Serum IgE studies and/or skin prick tests are indicated for the planning of treatment, for consideration of allergen-specific immunotherapy (desensitisation) and for diagnosing possible occupational rhinitis (Investigation of atopy).

Further investigations

  • Referral to an ENT specialist is warranted when

ARIA guidelines

  • ARIA (Allergic rhinitis and its impact on asthma) guidelines http://www.euforea.eu/about-us/aria.html, which have been drafted by an expert panel together in collaboration with the WHO, are research and treatment guidelines for general practitioners and specialists. The emphasis is on the concept "one airway, one disease". The connection and inter-relatedness of rhinitis and asthma must be borne in mind and whenever possible the investigations and treatment should include both conditions.

Treatment

  • Avoidance of allergens is indicated only if they cause significant symptoms. There is no need to avoid natural environmental allergens purely as a precaution.
  • Pharmacotherapy should include a combination of drugs from different pharmaceutical groups administered individually according to the symptoms and treatment response.
  • In allergic rhinitis, antihistamines are the most effective drugs to control sneezing and the production of mucus.
  • Antihistamines are also available as nasal sprays and eye drops.
  • Combination products (antihistamine + sympathomimetic) have a good effect on nasal congestion. They should not be used continuously for more than 10 days.
  • Nasal glucocorticoids are effective against all symptoms of allergic rhinitis. In children, products with low systemic bioavailability (mometasone, fluticasone propionate or furoate) should be preferred.
  • A nasal spray combining an antihistamine and a nasal glucocorticoid is also available for patients over 12 years of age.
  • Cromoglicate shows some effect against all symptoms of rhinitis, but its efficacy is only modest.
  • Leukotriene receptor antagonists may be suitable for the treatment of allergic rhinitis in patients with asthma.
  • Desensitisation therapy (hyposensitisation, allergen immunotherapy): see (Allergen-specific immunotherapy)
  • The management of other symptoms associated with allergic rhinitis:
    • eye drops for allergic ocular symptoms (mast cell stabilisers, antihistamines)
    • nasal sprays and solutions (water or oil based) to condition and moisten mucous membranes if the use of antihistamines or nasal glucocorticoids causes dryness or irritation
    • short-term use of sprays containing a sympathomimetic drug (no longer than for 7–10 days) if relief from nasal congestion is required before treatment with nasal glucocorticoids is started.

Pharmacotherapy in different types of rhinitis

Seasonal allergic rhinitis

  • Antihistamines alone may suffice as long as pollen counts remain low. Antihistamines can also be used as an add-on medication to topical therapy (nasal glucocorticoids) in pollen allergy when and as needed. Antihistamines administered directly to the nose or conjunctiva can be used instead of oral antihistamines.
  • Nasal glucocorticoids are most effective against nasal congestion when treatment is started before the onset of symptoms. Regular treatment should continue throughout the season. The patient can regulate the dosage depending on exposure (pollen count) and symptoms.
  • A combination product containing both an antihistamine and a nasal glucocorticoid
  • Cromoglicate is also commenced before the start of the pollen season and the onset of symptoms. Mast cell stabilising eye drops (cromoglicate, lodoxamide) are also available. Treatment should continue throughout the pollen season.

Perennial allergic rhinitis

  • Nasal glucocorticoids are often the drug of choice and can be used either intermittently or continuously.
  • Antihistamines may be used to control sneezing and excessive mucus production. They may also be used for a short period of time concomitantly with a sympathomimetic drug in mild nasal congestion.
  • A combination product containing both an antihistamine and a nasal glucocorticoid
  • Cromoglicate can be used all year round.
  • Leukotriene receptor antagonists may be also suitable in perennial rhinitis associated with asthma.

NARES (non-allergic rhinitis with eosinophilia syndrome)

  • Pharmacotherapy consists of the same medication as that used in allergic rhinitis.

Non-allergic hypersensitivity rhinitis, vasomotor rhinitis

  • The excessive mucus production is best managed with ipratropium nasal spray. The contraindications to anticholinergic medication should be remembered when treating elderly patients. Combination products containing antihistamines and sympathomimetic drugs may also be beneficial.

References

1. Brozek JL, Bousquet J, Baena-Cagnani CE et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 2010;126(3):466-76.  [PMID:20816182] http://www.euforea.eu/assets/pdfs/aria/2010-ARIA-Report.pdf

2. VSeidman MD, Gurgel RK, Lin SY et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg 2015;152(1 Suppl):S1-43.  [PMID:25644617]


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Citation

"Allergic Rhinitis." Evidence-Based Medicine Guidelines, Duodecim Medical Publications Limited, 2019. Evidence Central, evidence.unboundmedicine.com/evidence/view/EBMG/450679/all/Allergic_rhinitis.
Allergic rhinitis. Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. https://evidence.unboundmedicine.com/evidence/view/EBMG/450679/all/Allergic_rhinitis. Accessed March 24, 2019.
Allergic rhinitis. (2019). In Evidence-Based Medicine Guidelines. Available from https://evidence.unboundmedicine.com/evidence/view/EBMG/450679/all/Allergic_rhinitis
Allergic Rhinitis [Internet]. In: Evidence-Based Medicine Guidelines. Duodecim Medical Publications Limited; 2019. [cited 2019 March 24]. Available from: https://evidence.unboundmedicine.com/evidence/view/EBMG/450679/all/Allergic_rhinitis.
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TY - ELEC T1 - Allergic rhinitis ID - 450679 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/450679/all/Allergic_rhinitis PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -