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Allergic Rhinitis

By

James Fernandez

, MD, PhD, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University

Medically Reviewed Oct 2022
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Allergic rhinitis is seasonal or perennial itching, sneezing, rhinorrhea, nasal congestion, and sometimes conjunctivitis Allergic Conjunctivitis Allergic conjunctivitis is an acute, intermittent, or chronic conjunctival inflammation usually caused by airborne allergens. Symptoms include itching, lacrimation, discharge, and conjunctival... read more Allergic Conjunctivitis , caused by exposure to pollens or other allergens. Diagnosis is by history and occasionally skin testing. First-line treatment is with a nasal corticosteroid (with or without an oral or a nasal antihistamine) or with an oral antihistamine plus an oral decongestant.

Allergic rhinitis may occur seasonally or throughout the year (as a form of perennial rhinitis). Seasonal rhinitis is usually allergic. At least 25% of perennial rhinitis is nonallergic.

Seasonal allergic rhinitis (hay fever) is most often caused by plant allergens, which vary by season and geographic location. Common plant allergens include

  • Spring: Tree pollens (eg, oak, elm, maple, alder, birch, juniper, olive)

  • Summer: Grass pollens (eg, Bermuda, timothy, sweet vernal, orchard, Johnson) and weed pollens (eg, Russian thistle, English plantain)

  • Fall: Other weed pollens (eg, ragweed)

Causes also differ by region, and seasonal allergic rhinitis is occasionally caused by airborne fungal (mold) spores.

Perennial rhinitis is caused by year-round exposure to indoor inhaled allergens (eg, dust mite feces, cockroach components, animal dander) or by strong reactivity to plant pollens in sequential seasons.

Allergic rhinitis and asthma Asthma Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea... read more frequently coexist; whether rhinitis and asthma result from the same allergic process (one-airway hypothesis) or rhinitis is a discrete asthma trigger is unclear.

The numerous nonallergic forms of perennial rhinitis Nonallergic Rhinitis Rhinitis is inflammation of the nasal mucous membrane, with resultant nasal congestion, rhinorrhea, and variable associated symptoms depending on etiology (eg, itching, sneezing, watery or purulent... read more include infectious, vasomotor, drug-induced (eg, aspirin- or nonsteroidal anti-inflammatory drug [NSAID]–induced), and atrophic rhinitis and nonallergic rhinitis with eosinophilia (NARES).

Symptoms and Signs of Allergic Rhinitis

Patients have itching (in the nose, eyes, or mouth), sneezing, rhinorrhea, and nasal and sinus obstruction. Sinus obstruction may cause frontal headaches; sinusitis Sinusitis Sinusitis is inflammation of the paranasal sinuses due to viral, bacterial, or fungal infections or allergic reactions. Symptoms include nasal obstruction and congestion, purulent rhinorrhea... read more Sinusitis is a frequent complication. Coughing and wheezing may also occur, especially if asthma is also present.

Signs include edematous, bluish-red nasal turbinates and, in some cases of seasonal allergic rhinitis, conjunctival injection and eyelid edema.

Diagnosis of Allergic Rhinitis

  • Clinical evaluation

  • Occasionally skin testing, allergen-specific serum IgE tests, or both

Allergic rhinitis can frequently be diagnosed based on history alone. Diagnostic testing is not routinely needed unless patients do not improve when treated empirically; for such patients, skin tests Specific tests Allergic (including atopic) and other hypersensitivity disorders are inappropriate or exaggerated immune reactions to foreign antigens. Inappropriate immune reactions include those that are... read more are done to identify a reaction to pollens (seasonal) or to dust mite feces, cockroaches, animal dander, mold, or other antigens (perennial), which can be used to guide additional treatment.

Occasionally, skin test results are equivocal, or testing cannot be done (eg, because patients are taking drugs that interfere with results and cannot safely be withheld); then, an allergen-specific serum IgE test Specific tests is done.

A nasal smear to detect eosinophils can be done to confirm allergic rhinitis. Although the test is rarely done anymore, it can be a useful alternative to needlesticks in children or used as an additional tool in the evaluation of rhinitis. The sensitivity and specificity of the test is not clear (1 Diagnosis reference Allergic rhinitis is seasonal or perennial itching, sneezing, rhinorrhea, nasal congestion, and sometimes conjunctivitis, caused by exposure to pollens or other allergens. Diagnosis is by history... read more ). Eosinophilia detected on nasal smear plus negative skin tests suggests aspirin sensitivity or nonallergic rhinitis with eosinophilia (NARES).

Nonallergic perennial rhinitis is usually also diagnosed based on history. Lack of a clinical response to treatment for assumed allergic rhinitis and negative results on skin tests and/or an allergen-specific serum IgE test also suggest a nonallergic cause; disorders to consider include nasal tumors, enlarged adenoids, hypertrophic nasal turbinates, granulomatosis with polyangiitis Granulomatosis with Polyangiitis (GPA) Granulomatosis with polyangiitis is characterized by necrotizing granulomatous inflammation, small- and medium-sized vessel vasculitis, and focal necrotizing glomerulonephritis, often with crescent... read more Granulomatosis with Polyangiitis (GPA) , and sarcoidosis Sarcoidosis Sarcoidosis is an inflammatory disorder resulting in noncaseating granulomas in one or more organs and tissues; etiology is unknown. The lungs and lymphatic system are most often affected, but... read more Sarcoidosis .

Diagnosis reference

Treatment of Allergic Rhinitis

  • Antihistamines

  • Decongestants

  • Nasal corticosteroids

  • For seasonal or severe refractory rhinitis, sometimes desensitization

The most effective first-line drug treatments are

  • with or without oral or intranasal antihistamines

  • Oral antihistamines plus oral decongestants (eg, a sympathomimetic such as pseudoephedrine)

Intranasal decongestant sprays (eg, oxymetazoline, phenylephrine) are used for short-term relief of nasal congestion. Usually, they are not recommended for use for more than 3 consecutive days because rebound nasal congestion may occur.

Less effective alternatives include nasal mast cell stabilizers (eg, cromolyn) given 3 or 4 times a day, the intranasal H1 blocker azelastine 1 to 2 puffs twice a day, and nasal ipratropium 0.03% 2 puffs every 4 to 6 hours, which relieves rhinorrhea.

A combination of azelastine/fluticasone (137 mcg/50 mcg) is available. Initial dose is 1 spray each nostril twice a day.

Intranasal drugs are often preferred to oral drugs because less of the drug is absorbed systemically.

Intranasal saline, often forgotten, helps mobilize thick nasal secretions and hydrate nasal mucous membranes; various saline solution kits and irrigation devices (eg, squeeze bottles, bulb syringes) and kits are available over the counter, or patients can make their own solutions.

Montelukast, a leukotriene inhibitor, relieves allergic rhinitis symptoms but, due to a risk of mental health adverse effects (eg, hallucination, obsessive-compulsive disorder, suicidal thoughts and behavior), montelukast should be used only when other treatments are not effective or not tolerated.

Omalizumab, an anti-IgE antibody has been used to treat allergic rhinitis but probably has a limited role because less expensive, effective alternatives are available.

Prevention of Allergic Rhinitis

  • Avoidance of triggers

  • Sometimes desensitization

Avoidance of triggers

For perennial allergies, triggers should be removed or avoided if possible. Strategies include the following:

  • Removing items that collect dust, such as knickknacks, magazines, books, and soft toys

  • Using synthetic fiber pillows and impermeable mattress covers

  • Frequently washing bed sheets, pillowcases, and blankets in hot water

  • Frequently cleaning the house, including dusting, vacuuming, and wet-mopping

  • Removing upholstered furniture and carpets or frequently vacuuming them

  • Replacing draperies and shades with blinds

  • Exterminating cockroaches to eliminate exposure

  • Using dehumidifiers in basements and other poorly aerated, damp rooms

  • Using high-efficiency particulate air (HEPA) vacuums and filters

  • Avoiding food triggers

  • Limiting pets to certain rooms or keeping them out of the house

Adjunctive nonallergenic triggers (eg, cigarette smoke, strong odors, irritating fumes, air pollution, cold temperatures, high humidity) should also be avoided or controlled when possible.

Desensitization

Desensitization immunotherapy may be more effective for seasonal than for perennial allergic rhinitis; it is indicated when

  • Symptoms are severe.

  • The allergen cannot be avoided.

  • Drug treatment is inadequate.

First attempts at desensitization should begin soon after the pollen season ends to prepare for the next season; adverse reactions increase when desensitization is started during the pollen season because the person’s allergic immunity is already maximally stimulated.

Sublingual immunotherapy using 5–grass pollen sublingual tablets (Oralair®—an extract of 5 grass pollens: sweet vernal, orchard, perennial rye, timothy, and Kentucky blue grass) can be used to treat grass pollen-induced allergic rhinitis. An alternative is a sublingual tablet of timothy grass extract (Grastek®). Dosage is

  • For adults: One 300-IR (index of reactivity) tablet of the 5-grass pollen extract (Oralair®) or one 2800-BAU (bioequivalent allergy unit) tablet of the timothy grass extract (Grastek®) taken once a day

  • For patients aged 5 to 17 years: One 100-IR tablet of the 5-grass pollen extract on day 1, two 100-IR tablets simultaneously on day 2, then one 300-IR tablet once a day from day 3 onward

  • For patients aged ≥ 5 years with grass pollen–induced allergic rhinitis: One 2800-BAU tablet of the timothy grass pollen extract taken once a day

The first dose is given in a health care setting and patients should be observed for 30 minutes after administration because anaphylaxis may occur. If the first dose is tolerated, patients can take subsequent doses at home. Treatment is initiated 4 months before the onset of each grass pollen season and maintained throughout the season.

Sublingual immunotherapy using either ragweed pollen or house dust mite allergen extracts can be used to treat allergic rhinitis induced by these allergens.

Patients taking home immunotherapy for allergic rhinitis should carry a prefilled, self-injecting epinephrine syringe to use in case of an anaphylactic reaction.

Key Points

  • Seasonal rhinitis is usually an allergic reaction to pollens; perennial allergic rhinitis is caused by year-round exposure to indoor inhaled allergens or by strong reactivity to plant pollens in sequential seasons.

  • Patients with allergic rhinitis may have cough, wheezing, frontal headache, sinusitis, or, particularly in children with perennial rhinitis, otitis media.

  • Diagnosis of allergic rhinitis is usually based on the history; skin tests and sometimes an allergen-specific serum IgE test are needed only when patients do not respond to empiric treatment.

  • Try intranasal corticosteroids first because they are the most effective treatment and have few systemic effects.

  • Other treatments include oral and intranasal antihistamines and decongestants; intranasal mast cell stabilizers are less effective.

  • Desensitization sublingual immunotherapy is indicated when symptoms are severe, allergens cannot be avoided, or drug treatment is inadequate.

Drugs Mentioned In This Article

Drug Name Select Trade
Anacin Adult Low Strength, Aspergum, Aspir-Low, Aspirtab , Aspir-Trin , Bayer Advanced Aspirin, Bayer Aspirin, Bayer Aspirin Extra Strength, Bayer Aspirin Plus, Bayer Aspirin Regimen, Bayer Children's Aspirin, Bayer Extra Strength, Bayer Extra Strength Plus, Bayer Genuine Aspirin, Bayer Low Dose Aspirin Regimen, Bayer Womens Aspirin , BeneHealth Aspirin, Bufferin, Bufferin Extra Strength, Bufferin Low Dose, DURLAZA, Easprin , Ecotrin, Ecotrin Low Strength, Genacote, Halfprin, MiniPrin, St. Joseph Adult Low Strength, St. Joseph Aspirin, VAZALORE, Zero Order Release Aspirin, ZORprin
Contac Cold 12 Hour, Dimetapp Decongestant, Drixoral, ElixSure Cold, ElixSure Congestion, Entex, Genaphed , KidKare , Myfedrine, NASAL Decongestant, Nasofed, Nexafed, PediaCare Infants' Decongestant, Pseudo-Time, Silfedrine, Sudafed, Sudafed 12 Hour, Sudafed 24 Hour, Sudafed Children's Nasal Decongestant, Sudafed Congestion, Sudafed Sinus Congestion, Sudogest, Sudogest 12 Hour, Sudogest Children's , Tylenol Children's Simply Stuffy, Zephrex-D
12 Hour Nasal , Afrin, Afrin Extra Moisturizing, Afrin Nasal Sinus, Afrin No Drip Severe Congestion, Dristan, Duration, Genasal , Mucinex Children's Stuffy Nose, Mucinex Full Force, Mucinex Moisture Smart, Mucinex Sinus-Max, Mucinex Sinus-Max Sinus & Allergy, NASAL Decongestant, Nasal Relief , Neo-Synephrine 12-Hour, Neo-Synephrine Severe Sinus Congestion, Nostrilla Fast Relief, Reliable-1 12 hour Decongestant, RHOFADE, Sinex 12-Hour, Sudafed OM Sinus Cold Moisturizing, Sudafed OM Sinus Congestion Moisturizing, Upneeq, Vicks Qlearquil Decongestant, Vicks Sinex, Vicks Sinex Severe, Visine L.R., Zicam Extreme Congestion Relief, Zicam Intense Sinus
4-Way Nasal, Ah-Chew D, AK-Dilate, Anu-Med, Biorphen, Formulation R , Gilchew IR, Hemorrhoidal , Little Remedies for Noses, Lusonal, Mydfrin, Nasop, Nasop 12, Neofrin, Neo-Synephrine, Neo-Synephrine Cold + Allergy, Neo-Synephrine Extra Strength, Neo-Synephrine Mild, Ocu-Phrin, PediaCare Children's Decongestant, PediaCare Decongestant, PediaCare Infants' Decongestant, Sinex Nasal, Sudafed PE, Sudafed PE Children's Nasal Decongestant , Sudafed PE Congestion, Sudafed PE Sinus Congestion, Sudogest PE, Vazculep
Astelin, Astepro, Optivar
Atrovent, Atrovent HFA
Dymista
Singulair
Xolair, Xolair Prefilled
Adrenaclick, Adrenalin, Auvi-Q, Epifrin, EpiPen, Epipen Jr , Primatene Mist, SYMJEPI, Twinject
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NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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