About Allergic Rhinitis
Rhinitis is a very common disorder, caused by inflammation or irritation of the nasal mucosa. Patients are most often describing it as a stuffy nose, although some would rather describe it as runny nose or excessive sneezing. Besides nasal stuffiness, hypersecretion and sneezing, patients may complain of nasal itch and ocular symptoms.
Most common causes of nasal inflammation are viral infections and allergic response to airborne allergens. Response to irritants may cause similar symptoms, although signs of inflammation may not always be present. Allergic rhinitis occurs in patients whose immune system is producing a specific antibody, immunoglobulin E (IgE), due to sensitization to certain airborne allergen, like pollens, dust, molds, animal dander, etc. The disease often occurs in families with an allergic background, which is helpful in making diagnosis in patients who have rhinitis in a certain period of the year, or aggravation of nasal symptoms occurs in the environment typical of certain allergen.
Allergic rhinitis is categorized according to sensitivity to allergens that occur seasonally, like pollens, or to allergens that are all year round, like house dust mite, molds and animal dander, into seasonal and perennial allergic rhinitis. Allergy to pollens (hay fever, pollinosis) causes the same mechanism of inflammation in response to allergens, which is the result of binding of allergen to specific IgE antibody, but patients with pollen allergy usually complain more of sneezing and runny nose, while patients with allergy to perennial allergens more often complain of obstruction, while episodes of sneezing and runny nose occur only when exposed to higher concentrations of allergens (cleaning the house, around pets).
Viral rhinitis is lasting up to 10 days, and it is a part of the common cold syndrome. In a short-lived rhinitis, lasting for 7 to 10 days, sometimes it is not easy to differentiate between potential causes of the disorder, if general symptoms of infection, like fever and malaise, are not present.
In a long-living rhinitis, it is important to differentiate between infectious, allergic, non-allergic non-infectious rhinitis, and chronic rhinosinusitis.
Non-allergic non-infectious rhinitis is characterised by nasal symptoms that may be induced by exposure to irritants, tobacco smoke, temperature and humidity changes, hormonal disorders, pregnancy, use or abuse of certain drugs, most commonly nasal decongestants, and emotional stress. Itch and ocular symptoms are more common in allergic rhinitis, while other symptoms, like nasal stuffiness, runny nose and sneezing may affect patients with allergic and non-allergic rhinitis.
Patients with allergic rhinitis often have symptoms after exposure to irritants, temperature and humidity changes, like patients with non-allergic rhinitis, and such exposures may sometimes cause more severe symptoms than exposure to allergens. Eye symptoms such as itching, irritation, redness or tearing, are often present in patients with allergic rhinitis. This is called allergic conjunctivitis.
Diagnosis
The diagnosis of rhinitis is based on the symptoms of the patient, combined with a physical examination. The cause of such rhinitis (allergy, infections,…) may be suspected and may need to be confirmed. The diagnosis of allergic rhinitis is confirmed by proving sensitivity to certain allergen in allergy testing, typically in a skin prick test, and by proving specific antibody IgE in patient’s serum. Diagnosis of non-allergic-non-infectious rhinitis is made by exclusion of allergies and other causes. Excessive response to triggers may be tested in a provocation test, if the diagnosis is not clear. Physical examination will include anterior rhinoscopy or nasal endoscopy by which the physician will be able to see the inside of the nose in order to ascertain if the mucosa is inflamed, the presence of polyps or other abnormalities. In some cases, more sophisticated techniques, such as rhinomanometry or acoustic rhinometry may be necessary, sometimes after a challenge test. Ocasionally a CT-scan may be performed to confirm the presence of related conditions such as sinusitis.
Management
Treatment includes avoidance of allergens, medical treatment and allergen immunotherapy (allergy vaccines, drops or tablets with allergens). Avoidance of allergens means reduction of allergen load to the respiratory system from the environment, including workplace, which is not easy to accomplish. Medical treatment is usually necessary to control symptoms, and it includes antihistamines, nasal or in tablets, and nasal glucocorticoids (steroids). Antihistamines should be second generation, which do not cause sedation, and such treatment shows more efficacy on runny nose, sneezing and nasal itch than on nasal stuffiness. Nasal steroids are more potent in improving nasal patency than antihistamines, and are at least as potent in the control of all other nasal and ocular symptoms. Nasal patency may be improved by nasal or oral decongestants, but such treatment should be reduced to as short period as possible. as after few days of use of nasal decongestants rebound congestion may occur and patients remain with a need for nasal decongestants to improve nasal airways even after allergens are not around (like after pollen season). Viral rhinitis is a part of common cold and usually lasts up to 10 days. Besides previously mentioned nasal symptoms, like obstruction, runny nose and sneezing, other symptoms also often occur, like sore throat, cough and headache. Treatment, analgesics and antipyretics, should improve general symptoms. Nasal symptoms are improved with saline nasal douching. Good hydration, drinking fluids and resting are also recommended. Some patients respond to antileukotriene drugs which are usually prescribed for asthma. For non-allergic-non-infectious rhinitis, such patients should avoid exposure to triggers that cause symptoms. If symptoms are often present even without environmental triggers, they may be treated with nasal steroids, if their dominant symptom is obstruction or nasal anticholinergic ipratropium bromide, if they complain of runny nose.
Coping
It is important to know that rhinitis may be accompanied by other upper airways disease, like rhinosinusitis or nasal polyps, and obstructive lower airways disease, like asthma. Therefore, the treating physician should ask about such symptoms and perform the necessary tests to confirm or refute their presence. Patients with allergic rhinitis may have an affected quality of life, with symptoms affecting their sleep or their performance at school or at work. To avoid this, it is important to know when symptoms occur more often (time of the year, certain places or performing certain activities). Avoid contact with the causative allergens whenever possible. Avoid smoky environments and sudden temperature changes. Nasal douches with saline or treated seawater are a safe hygienic measure which helps to remove accumulated mucus and allergens present in the upper airway, soothing irritation and dryness. Use a mask that covers nose and mouth when you cannot avoid the presence of allergens. Follow your physician’s recommendations about treatment: some medications should be used on demand, but others should be used routinely for long periods of time. If you have to drive or operate dangerous machinery, make sure you have been prescribed a non-sedative antihistamine. If eye symptoms disturb you, consider using eye drops based on saline or artificial tears and protect eyes with glasses if eye symptoms are severe.