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allergic rhinoconjunctivitis (hayfever)

Etiology: 1) IgE-mediated hypersensitivity to nasally-inhaled allergens 2) seasonal allergens a) ragweed: mid August until 1st frost b) tree pollen: March to May c) grass pollen: May to July 3) perennial allergens a) dust mites b) molds c) animal dander or saliva d) cockroach antigen 4) see 'allergens causing allergic rhinitis' Pathology: 1) irritation & inflammation of mucous membranes of eyes & upper respiratory tract 2) generally requires about 3 seasonal exposures for a patient to develop clinically significant symptoms to a new aeroallergen 3) nasal polyps may cause refractory nasal obstruction Genetics: - implicated genes SDAD1 Clinical manifestations: 1) sneezing 2) rhinorrhea (thin, clear nasal discharge) 3) postnasal drip a) erythematous, sore throat b) inflamed tonsils 4) nasal congestion a) pale, swollen nasal mucosa b) turbinate edema c) may lead to loss of taste &/or smell d) may lead to sinusitis, acute or chronic 5) conjunctivitis a) ocular itching b) lacrimation, clear watery discharge (tears) c) conjunctival injection 6) cough 7) frequent nose rubbing (allergic salute) 8) dry mouth 9) halitosis 10) fatigue 11) sleep disturbances 12) dark circles under the eyes (allergic shiners) Laboratory: 1) nasal cytology (smears) may show eosinophils 2) skin testing for allergen-specific IgE 3) radioallergosorbent [RAST] testing Radiology: - computed tomography of paranasal sinuses Complications: 1) bronchitis 2) asthma (coexisting asthma not uncommon) Differential diagnosis: 1) infectious agents - viral, bacterial or fungal rhinitis - sinusitis 2) non-infectious a) vasomotor rhinitis - smoke - air pollution - perfumes - detergents & soaps - solvents or fumes - changes in temperature, light, or atmospheric pressure - emotion b) rhinitis medicamentosa - sympathomimetic nasal drops or sprays - cocaine - antihypertensives - reserpine - guanethidine - hydralazine - oral contraceptives - antidepressants c) nasal obstruction - nasal polyps - deviated nasal septum - nasal neoplasm - foreign body - hypertrophic turbinates or adenoids d) systemic disorders - rhinitis of pregnancy - hypothyroidism - Wegener's granulomatosis - sarcoidosis - ciliary - cystic fibrosis - Sjogren syndrome e) cerebrospinal fluid leak (CSF rhinorrhea) f) atrophy of nasal mucosa Management: 1) topical nasal steroids (most effective agents) a) also reduces ocular symptoms of allergic conjunctivitis [12] b) intranasal glucocorticoids 1] beclomethasone (Beconase, Vancenase) - 1 spray (42 ug) BID-QID 2] flunisolide (Nasalide) - 2 sprays (50 ug) BID 3] triamcinolone (Nasocort) - 2 sprays (110 ug) QD 4] budesonide [3] 2) antihistamines a) chlorpheniramine 4 mg PO TID/QID b) loratadine (Claritin) 10 mg PO QD c) astemizole (Hismanal) 10 mg PO QD d) fexofenadine (Allegra) 60 mg PO BID e) azelastine (Astelin) 2 sprays/nostril BID (nasal spray) f) azelastine (Optivar) ophthalmic 1 drop BID 3) decongestants - effective but associated with rebound congestion (rhinitis medicamentosa) - pseudoephedrine (Sudafed) 30-60 mg QID - oxymetazoline (Afrin) intranasal enhances effectiveness of intranasal glucorticoids without rebound congestion 4) montelukast (Singulair) 10 mg PO QD (adults) is NOT more effective than antihistamines or decongestants 5) prednisone 40 mg PO QD for 5 days for very severe symptoms 6) nasal chromolyn (Nasalchrom) a) one spray (5.2 mg) TID/QID b) prophylactic dosing c) variable response 7) tolerance induction (immunotherapy) a) injection of allergen defined by RAST or skin testing b) best response with seasonal allergies c) patients with severe rhinitis not well controlled with intranasal glucocorticoids, antihistamines, decongestants [10] d) contraindicated with beta blocker therapy 1] systemic or ocular 2] increases likelihood of adverse systemic reaction 3] diminished response to epinephrine rescue e) subcutaneous immunotherapy (SCIT) or 'allergy shots' may someday be replaced by daily sublingual-dissolving tablets that contain allergens [11,14] 8) pregnancy a) oxymetazoline nasal spray for 5 days b) pseudoephedrine c) intranasal cromolyn d) intranasal beclomethasone e) chlorpheniramine if unresponsive to cromolyn f) treat sinusitis 9) patient education a) dust mites 1] keep humidity < 50% 2] wash sheets in hot water every week 3] encase mattress, boxspring & pillows in plastic 4] remove carpet, dust floors frequently b) mold 1] keep humidity < 50% 2] vent bathrooms & clean with fungicidal agent 3] remove books & plants from the bedroom 4] install air filters c) animal dander 1] remove pets from house 2] bathe pets frequently (at least every week) 3] shampoo carpets d) pollen 1] avoid outdoors during pollen season 2] keep windows closed (use air conditioning) 3] install air filter units for air conditioning 10) Refer to allergist if response to treatment is poor & diagnosis of allergic rhinitis seems probable 11) Refer to ENT specialist if response to treatment is poor & diagnosis of allergic rhinitis is questionable.

Related

allergen skin testing allergens causing allergic rhinitis radioallergosorbent [RAST] testing

General

allergic rhinitis (hay fever, ragwood allergy) allergic conjunctivitis; Angelucci's syndrome

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 84-86
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
  3. Journal Watch 22(9):70, 2002 Rinne et al, Clin Immunol 109:426, 2002
  4. Singulair (Montelukast) for Seasonal Allergic Rhinitis Prescriber's Letter 10(2):9 2003 Detail-Document#: 190210 (subscription needed) http://www.prescribersletter.com
  5. Meltzer EO. Evaluation of the optimal oral antihistamine for patients with allergic rhinitis. Mayo Clin Proc. 2005 Sep;80(9):1170-6. PMID: 16178497
  6. Prescriber's Letter 13(4): 2006 Drug Treatments for Allergic Rhinitis Detail-Document#: 220414 (subscription needed) http://www.prescribersletter.com
  7. Prescriber's Letter 14(1): 2007 Ophthalmic Medications for Allergic Conjunctivitis Detail-Document#: 230106 (subscription needed) http://www.prescribersletter.com
  8. Wahn U et al Efficacy and safety of 5-grass-pollen sublingual immunotherapy tablets in pediatric allergic rhinoconjunctivitis. J Allergy Clin Immunol 2009 Jan; 123:160 PMID: 19046761 - Bufe A et al Safety and efficacy in children of an SQ-standardized grass allergen table for sublingual immunotherapy. J Allergy Clin Immunol 2009 Jan; 123:167. PMID: 19130937 - Frew AJ. Sublingual immunotherapy. N Engl J Med. 2008 May 22;358(21):2259-64. Review. PMID: 18499568
  9. Prescriber's Letter 16(8): 2009 COMMENTARY: Neuropsychiatric Adverse Effects with Leukotriene Modifiers GUIDELINES: NAEPP Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007 GUIDELINES: The Diagnosis and Management of Rhinitis: An Updated Practice Parameter Detail-Document#: 250805
  10. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, American College of Physicians, Philadelphia 2006, 2009
  11. Durham SR et al. Long-term clinical efficacy in grass pollen-induced rhinoconjunctivitis after treatment with SQ-standardized grass allergy immunotherapy tablet. J Allergy Clin Immunol 2010 Jan; 125:131 PMID: 20109743
  12. Prenner BM et al. Mometasone furoate nasal spray reduces the ocular symptoms of seasonal allergic rhinitis. J Allergy Clin Immunol 2010 Jun; 125:1247 PMID: 20434199 http://dx.doi.org/10.1016/j.jaci.2010.03.004
  13. Baroody FM et al. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol 2011 Apr; 127:927. PMID: 21377716
  14. Didier A et al. Sustained 3-year efficacy of pre- and coseasonal 5-grass- pollen sublingual immunotherapy tablets in patients with grass pollen-induced rhinoconjunctivitis. J Allergy Clin Immunol 2011 Sep; 128:559 PMID: 21802126