Allergic Rhinitis

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Allergic Rhinitis

• By Alex Pearce-Smith

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Scenario

• A 12 yr old boy comes into see you with his mum
  in June. He complains of a persistant runny nose
  and sore eyes for the last 3 wks. You suspect
  seasonal rhinitis.
• What other points would you want to know from the
  history?
• What examination would you perform?
• How would you manage this?

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What are these examples of?
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Pathophysiology
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Sub-types

• Seasonal (hayfever)
• Grass, Tree pollen allergens, same time each
  year.
• Perennial
• House dust mites, feathers, animal danders
  throughout the year.
• Occupational
• Workplace e.g. flour allergy in bakers.

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Epidemiology

• Approximately 25 of UK population
• Age Matters
• Seasonal more common in children
• Perennial more common in adults
• Increasing age a negative risk factor
• Seasonal rhinitis more predisposition to itch,
  sneezing and diurnal symptoms.
• Perennial catarrh more prevelant and more
  likely to be diagnosed with asthma.

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What to look for..

• Which of these are typical symptoms of Allergic
  Rhinitis?
• Facial pain
• Post nasal drip
• Persistent runny nose
• Unilateral Symptoms
• Nasal obstruction
• Nosebleeds
• Nasal itch
• Violent sneezing in bouts
• Conjunctivitis

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Classification
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Treatment

• Mild and Intermittent
• Topical (rapid relief) e.g. Azelastine.
• Oral e.g. Cetirizine, Loratadine,
  Fexofenadine.
• Or LTRA (e.g. Montelukast esp. in asthmatics).
• Mild but persistent/ Moderate-Severe but
  Intermittent.
• Trial of above /- decongestant (max 2/52)
• Nasal Corticosteroids e.g.Fluticasone,
  Budesonide, Mometasone.
• Review after a month
• If improved continue for 1/12
• if not then step up treatment.

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Treatment

• Moderate/Severe and Persistent.
• 1) Nasal corticosteroids, 2)Antihistamines, 3)
  LTRAs
• Review after 2-4 wks
• If improved continue for further month
• If not rv diagnosis and compliance and consider
• Increase corticosteroid
• Add antihistamine (if itch and sneeze)
• Add Ipratropium (if rhinorrhoea)
• Add decongestant/ oral steroids .. refer

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Consider Asthma

• Strong link between allergic rhinitis and asthma.
• If known asthmatic then review asthma control.
• If no diagnosis of asthma try these 4 Qus.
• Have you had an attack/recurrent wheeze?
• Do you have a troublesome cough esp. at night?
• Do you cough or wheeze after exercise?
• Does your chest feel tight?
• If yes to any of these then review asthma.

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Allergen Avoidance.Can you think of 3?

• Allergen impermeable covers fo matresses and
  pillows.
• Wash bedding in hot water regularly.
• Remove animals, teddys and carpets from bedrooms.
• Air-conditioning.
• Air Filters in bedroom
• Dehumidifier
• Vented drier to dry clothes
• Minimize upholstered furniture.

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Pollen Avoidance. Can you think of 3 measures..

• Stay indoors and shut windows!
• Wear sunglasses.
• Wash hair and change clothes after returning from
  exposure to high pollen count.
• Avoid drying clothes outdoors.
• Pollen filters in cars.
• Avoid grassy places.
• Take a holiday by the sea when sx at worst!
• Vasaline around nostrils
• Pets carry pollen

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Testing?

• Not usually necessary but may be useful if
  struggling to isolate allergen or has suffered a
  severe reaction.
• Skin Prick testing
• Skin Prick Testing
• RAST (specific IgE)
• If skin prick inappropriate due to severe
  previous reaction/ on antihistamine.

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Referral?

• Referral should be considered if either
• refractory to treatment e.g. 6 weeks with nasal
  steroids
• unilateral nasal symptoms
• nasal perforation, ulceration or collapse
• sero-sangionous discharge
• high nasal cavity crusting
• recurrent cellulitis
• urgent referral required for periorbital
  cellulitis

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Scenario

• A 12 yr old boy comes into see you with his mum
  in June. He complains of a persistant runny nose
  and sore eyes for the last 3 wks. You suspect
  seasonal rhinitis.
• What other points would you want to know from the
  history?
• What examination would you perform?
• How would you manage this?

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Questions?

• References
• GP notebook
• CKS
• ARIA guidelines
• Allergyuk.org
• Patient.co.uk