Allergic Rhinitis

Allergic rhinitis is an inflammation of the nasal mucous membrane caused by an IgE dependent allergic reaction.

Classification:

1.) Depending on the duration of symptoms:

a) intermittent – duration <4 days per week or <4 weeks..;

b) persistent – duration >4 days per week and >4 weeks;

2.) Depending on the intensity of symptoms:

(a) Mild – none of the below mentioned criteria;

b) moderate or severe – presence of ≥1 of the following symptoms: sleep disturbance, difficulties experienced in everyday, recreational or sports activities, work or study problems, severe symptoms;

3.) Depending on the allergens causing the symptoms:

a) seasonal (intermittent) – caused by seasonal allergens. In some countries with a long (year-round) flowering period of causative plants, seasonal (intermittent) rhinitis may acquire persistent criteria.

b) year-round (perennial) – caused by household allergens.

Etiological factors

1) Respiratory allergens:

a) Pollen from plants (especially wind-pollinated plants) – most often pollen from grasses and cereals (e.g. thymopheic meadow pollen, meadow minnow, hedgehog, meadow fescue and rye), weeds (common wormwood, less often plantain and weed) and trees (birch, less often alder, hazel, oak, ash, hornbeam, etc.);

b) allergens of the mite of domestic dust and the mite of flour granaries;

c) coat, epidermis and secrets (saliva, urine) of animals – cat, dog, rodents (e.g. rabbit, guinea pig, hamster, rats, mice), horse, cattle;

d) mold fungi (e.g. Alternaria, Cladosporium) and yeastlike fungi (e.g. Candida albicans, Saccaromyces

e) others – cockroach allergens (can cross-react with dust mites), Benjamin ficus (cross-react with latex allergens), bacterial enzymes used in industry for soaps and other detergents;

2) Food allergens – symptoms of rhinitis may (rarely) be combined with other symptoms of anaphylaxis caused by food allergens; there are cross-reactions between food and respiratory allergens → Table 4.32-1;

3) Professional allergens – latex (mainly latex gloves), compounds with a high molecular weight – proteins from plants and animals (e.g. animal proteins). Allergens from laboratory and domestic animals, dust from cereals, tobacco, pepper, tea, coffee, cocoa, dried fruit, enzymes from detergents and enzymes used in the pharmaceutical industry, fish and seafood), compounds of low molecular weight.

CLINICAL MAPTER AND ACTIVITIES

Typical symptoms: watery discharge from the nasal cavity; sneezing, often paroxysmal; nasal congestion and thick, mucous discharge; itching in the nasal cavity, often also itching and red conjunctiva, itching of the palate or throat, itching in the ears; smell disturbance; dry oral mucous membrane; occasionally, sleep disturbance, concentration and learning ability, slightly elevated body temperature, headache and low mood.

Frequent watery discharge from the nose and sneezing, more typical for allergic rhinitis caused by pollen plants (seasonal), nasal congestion – for chronic (all year round) allergic rhinitis. In 70% of patients, symptoms increase at night and in early morning hours.

Symptoms appear during prolonged exposure to a specific allergen – seasonally (e.g. during pollination of a plant to which the patient is sensitive) or all year round (e.g. in patients sensitive to house dust mites). In some patients the symptoms decrease or disappear on their own after a prolonged exacerbation of allergic rhinitis.

Inflammation of the mucous membrane of the nose, especially in the case of persistent allergic rhinitis, can cause blockages in the mouths of the sinuses of the appendage nose, which increases the risk of bacterial inflammation. Allergic rhinitis is associated with a 3-8-fold increase in the risk of asthma. Patients with seasonal/intermittent allergic rhinitis in the period of dusting often have symptoms of bronchial hyperreactivity, in patients with bronchial asthma the presence of allergic rhinitis impairs its (bronchial asthma) flow.

DIAGNOSTIC

Additional research methods

1. Studies confirming the diagnosis of an allergy: positive results of skin prik tests with respiratory allergens (the most sensitive, fastest and cheapest study to recognize allergic rhinitis), an increase in serum IgE specific concentrations (not recommended for screening purposes). In case of conflicting results, a nasal provocation test can be performed as an exception.

2. Predominant rhinoscopy and endoscopy of the nose: bilateral, not always symmetrical swelling of the mucous membrane, which has watery secretions (thick in chronic allergic rhinitis), mucous membrane pale or cyanosis, can be hyperemic, sometimes – nasal polyps.

3. Nasal smear: increased percentage of eosinophils ≥2 % (usually during exacerbations), mast cells or basophils, goblet cells >50 %; results are not specific for allergic rhinitis and similar in non-allergic rhinitis.

4. Nasal and appendicular sinus CT: to be used in individual cases, allows a reliable assessment of the concomitant inflammation of the appendicular sinuses.

TREATMENT

General recommendations

1.) Avoid prolonged exposure to allergens responsible for symptoms (e.g. limited outdoor exposure during dusting of a plant to which the patient is sensitive; abandonment of pets when sensitizing the epidermis; comprehensive methods to combat tick-borne house dust can be useful). You can use applications for computers or smartphones that provide personalized dusting calendars, questionnaires on symptoms of allergic rhinitis and asthma, as well as treatment recommendations.

2.) Nasal cavity washing or atomization of isotonic, hypertonic salt solution or sterile sea water.

3.) Indications for otolaryngological consultation: suspected complications or chronic sinusitis, lack of response to empirical treatment, recurrent otitis media, unilateral or untreated symptoms, nasal bleeding, septal curvature and other anatomical changes, nasal polyps.

4.) Indications for surgical treatment: development of complications or concomitant pathology in the form of pharmacologically resistant lower nasal hypertrophy; septal curvature affecting nasal function.

Diagnostic criteria

In most cases, a diagnosis can be made based on subjective and objective examinations. Clinically significant allergic rhinitis is only indicated by the relationship between the results of skin allergic tests (handicap tests, scarification tests) and/or by the determination of specific IgE in the blood and history data. Every allergic rhinitis patient should be checked for asthma (anamnesis and basic spirometry).

Pharmacological treatment

1. GCS

2. Antihistamines – H1-blockers

3. Leukotrien receptor antagonists

4. Cromonese

5. Medicines narrowing mucous membrane vessels: For temporary and rapid recovery of nasal cavity permeability, it may be used in the nasal form (ephedrine, phenylephrine, naphasoline, xylomethasoline, oximethasoline, tetrizoline, thymasoline; not taken longer than 5 days due to the risk of drug rhinitis) or orally (ephedrine, phenylephrine, pseudoephedrine); not administered to women during pregnancy, patients with arterial hypertension, heart disease, hyperthyroidism, prostate hyperplasia, glaucoma, mental disorders, patients using β-blockers and monoamine oxidase inhibitors; in many patients this may be the cause of insomnia).

6. Anticholinergic nasal preparations reduce the amount of secretions, are useful in the treatment of idiopathic rhinitis.

7. Allergen-specific immunotherapy (hyposensitization): the most effective treatment for allergic rhinitis caused by respiratory allergen allergy. Reduces/liquidates symptoms and the need for medication, and reduces the risk of asthma and allergies to other inhaled allergens by a factor of three.