Introduction
Pathophysiology
Classification
Description | |
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IgE-mediated (allergic)
| • IgE-mediated inflammation of the nasal mucosa, resulting in eosinophilic and Th2-cell infiltration of the nasal lining • Further classified as intermittent or persistent |
Autonomic
| • Drug-induced (rhinitis medicamentosa) • Hypothyroidism • Hormonal • Non-allergic rhinitis with eosinophilia syndrome (NARES) |
Infectious
| • Precipitated by viral (most common), bacterial, or fungal infection |
Idiopathic
| • Etiology cannot be determined |
Diagnosis and investigations
History | Physical examination |
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Personal
• Nasal itch • Rhinorrhea • Sneezing • Eye involvement • Seasonality • Triggers
Family
• Allergy • Asthma
Environmental
• Pollens • Animals • Flooring/upholstery • Mould • Humidity • Tobacco exposure
Medication/drug use
• Beta-blockers • ASA • NSAIDs • ACE inhibitors • Hormone therapy • Recreational cocaine use
Quality of life
• Rhinitis-specific questionnaire
Comorbidities
• Asthma • Mouth breathing • Snoring • Sinus involvement • Otitis media • Nasal polyps • Conjunctivitis
Response to previous medications
• Second-generation oral antihistamines • Intranasal corticosteroids |
Outward signs
• Mouth breathing • Rubbing the nose/transverse nasal crease • Frequent sniffling and/or throat clearing • Allergic shiners (dark circles under eyes)
Nose
• Mucosal swelling, bleeding • Pale, thin secretions • Polyps or other structural abnormalities
Ears
• Generally normal • Pneumatic otoscopy to assess for Eustachian tube dysfunction • Valsalva’s maneuver to assess for fluid behind the ear drum
Sinuses
• Palpation of sinuses for signs of tenderness • Maxillary tooth sensitivity
Posterior oropharynx
• Postnasal drip • Lymphoid hyperplasia (“cobblestoning”) • Tonsillar hypertrophy
Chest and skin
• Atopic disease • Wheezing |
History
Physical examination
Diagnostic tests
Treatment
Allergen avoidance
Antihistamines
Usual adult dose | Usual pediatric dose | |
---|---|---|
Oral antihistamines (second generation)
| ||
Cetirizine (Reactine) | 1-2 tablets (5 mg) once daily 1 tablet (10 mg) once daily | 5-10 mL (1-2 teaspoons) once daily (children’s formulation) |
Desloratadine (Aerius) | 1 tablet (5 mg), once daily | 2.5-5 mL (0.5-1.0 teaspoon) once daily (children’s formulation) |
Fexofenadine (Allegra) | 1 tablet (60 mg) every 12 hours (12-hour formulation) 1 tablet (120 mg), once daily (24-hour formulation) | Not currently indicated for children under 12 years of age |
Loratadine (Claritin) | 1 tablet (10 mg), once daily | 5-10 mL (1-2 teaspoons) once daily (children’s formulation) |
Intranasal corticosteroids
| ||
Beclomethasone (Beconase) | 1-2 sprays (42 µg/spray) EN, twice daily | 1 spray (42 µg/spray) EN, twice daily |
Budesonide (Rhinocort) | 2 sprays (64 μg/spray) EN, once daily or 1 spray EN, twice daily | 2 sprays (64 μg/spray) EN, once daily or 1 spray EN, twice daily (do not exceed 256 μg) |
Ciclesonide (Omnaris) | 2 sprays (50 µg/spray) EN, once daily | Not indicated for children under 12 years of age |
Fluticasone furoate (Avamys) | 2 sprays (27.5 µg/spray) EN, once daily | 1 spray (27.5 µg/spray) EN, once daily |
Fluticasone propionate (Flonase) | 2 sprays (50 µg/spray) EN, once daily or every 12 hours (for severe rhinitis) | 1-2 sprays (50 µg/spray) EN, once daily |
Mometasone furoate (Nasonex) | 2 sprays (50 µg/spray) EN, once daily | 1 spray (50 µg/spray) EN, once daily |
Triamcinolone acetonide (Nasacort) | 2 sprays (55 µg/spray) EN, once daily | 1 spray (55 µg/spray) EN, once daily |
Leukotriene receptor antagonists
| ||
Montelukast | 1 tablet (10 mg), once daily | Not currently approved for patients under 15 years of age |
Intranasal corticosteroids
Leukotriene receptor antagonists
Allergen immunotherapy
Other therapeutic options
Conclusions
Key take-home messages
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Allergic rhinitis is linked strongly with asthma and conjunctivitis.
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Allergen skin testing is the best diagnostic test to confirm allergic rhinitis.
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Intranasal corticosteroids are the mainstay of treatment for most patients that present to physicians with allergic rhinitis.
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Allergen immunotherapy is an effective immune-modulating treatment that should be recommended if pharmacologic therapy for allergic rhinitis is not effective or is not tolerated.