MARINA DEL REY, Calif. - Effective management of allergic rhinitis consists of the following: avoidance, pharmacologic therapy and allergen immunotherapy, according to Chad Oh, MD.
However, before management must come diagnosis. Especially important is determining if the patient has allergic or infectious rhinitis.
"To establish a diagnosis of allergic rhinitis, it is important to get a good history from the patient. This will help you determine if there is a seasonal variation of symptoms. For example, a patient who has symptoms only during February or March probably has allergies to grass or tree pollens, whereas, a patient with perennial symptoms may have an allergy to dust mites or molds," said Oh at the recent Second Annual Infectious Diseases in Children Symposium West held here.
During the physical exam, it is important to look at nasal secretions. A clear nasal discharge is consistent with allergic rhinitis, while a purulent nasal discharge may indicate an infection.
"Sometimes a simple physical exam may not be enough. Then, you introduce rhinoscopy. Diagnostic rhinoscopy can be done quite easily. In terms of making the diagnosis, you can do specific immunoglobulin E (IgE) antibodies by skin testing or an in vitro test. Although most people don't do it, nasal cytology can help you significantly in terms of making the diagnosis of allergic rhinitis or infectious rhinitis," he added.
Sinusitis is a complication of allergic rhinitis. In these patients, one nostril will look more swollen than the other. On one side, the nasal mucosa will be thin and normal, and on the other side, it will be thick.
"When there is a suspicion of nasal polyps or if you really want to make sure that there is purulent discharge coming out of the maxillary sinus opening, then you can do rhinoscopy. It is well tolerated by patients, except sometimes by very young children. Basically, it is painless," Oh said.
The main problem is that patients will have sneezing from the fine thread. But, rhinoscopy can give you important information about the presence or absence of nasal polyps and the source of purulent discharge."
The hallmarks of allergic rhinitis in nasal mucosa include vasodilatation and edema formation. When there is significant vasodilatation and edema formation, normally, you see clear, watery, nasal discharge. When there is engorgement of the mucous glands and goblet cells, you will see mucoid or viscous discharge. Both are typical with allergic rhinitis.
"If you look at patients' nasal secretion, there is a significant eosinophilic infiltration into the tissue," he explained.
The best way to manage allergic rhinitis is avoidance. However, if you can't avoid allergens, the second choice is pharmacologic management, such as antihistamines, decongestants, anticholinergics and steroids. If this pharmacologic management is not sufficient, immunotherapy can be used.
When choosing a medication to treat allergic rhinitis, keep in mind that antihistamines will take care of sneezing and secretions, but they have a minimal effect on congestion. "So before you add a nasal steroid to antihistamines, you may want to consider a decongestant, because approximately 40% of patients with allergic rhinitis have the main complaint of congestion. So, it is important to remember a decongestant in addition to antihistamines," he said.
The American College of Allergy, Asthma and Immunology recommends using an antihistamine and/or a decongestant first. If the patient fails or this combination is not sufficient, then use a nasal steroid. Nasal steroids will relieve sneezing, congestion and secretions. However, there is always the chance of complications or adverse events from steroids.
"Cromolyn will help reduce sneezing, congestion and secretions, but the effect is very mild and you have to use it three to four times a day. This leads to problems with compliance. Anticholinergics are the drug of choice for vasomotor rhinitis and patients who predominately have secretions. Again, the first-line drugs for allergic rhinitis are antihistamines, which are effective in reducing itching, sneezing and rhinorrhea. They also reduce the symptoms of allergic conjunctivitis that are experienced by approximately 10% of allergic rhinitis patients," Oh said.
Allergy immunotherapy should be considered for severe symptoms, when patients fail other treatment modalities, with comorbid conditions and to prevent worsening of the condition.
For more information:
- Oh C. Management of allergic rhinitis in children. Presented at the Second Annual Infectious Diseases in Children est. Feb. 26-27, 2000. Marina del Rey, Calif.
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