• The late phase occurs 4 to 12 hours later, typically featuring more prominent nasal congestion. The pathophysiology of this phase is largely dominated by eosinophils and basophils recruited by IL-4, IL-5, and IL-13 produced in the early phase.
• Table 12–1 summarizes the relevant AR guideline action statements.
• A detailed history and physical is the first step in the work-up for AR and includes determining temporal features of symptoms (ie, seasonal, perennial, persistent, intermittent, exposure associated); identification of specific triggers is also helpful; obtaining a family history is important and will frequently be positive for atopic dermatitis, asthma, or AR; finally, determining the severity of symptoms and careful attention to any episodes of anaphylaxis are necessary. Common symptoms of AR are listed below.
Symptoms
• Nasal, ocular, palatal, or throat itching
• Clear anterior rhinorrhea
• Post-nasal drip
• Sneezing
• Nasal obstruction/congestion
• Decreased sense of smell
• Throat clearing
• Cough, malaise, or fatigue (sometimes the only complaints in children with AR)
• There are several physical exam findings present in AR that are absent in other diseases with similar symptoms.
• Although the definitive diagnosis is made with confirmation of an Ig-E mediated response to allergens on serum or skin testing, often history and physical exam are enough to make an initial diagnosis of AR and initiate empiric treatment. Further testing is indicated whenever the diagnosis is in question, patients have failed appropriate empiric treatment, or when the causative agent needs to be identified to guide treatment.
• The exam includes the following.
Table 12–1. Summary of AAO-HNS Allergic Rhinitis (AR) Guideline Action Statements
Source: Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: Allergic rhinitis. Otolaryngol Head Neck Surg. 2015;152(1 Suppl):S1-43. .
• Eyes
1. Red and watery
2. Conjunctival swelling
3. Allergic shiners—darkening and puffiness under the eyes secondary to venous pooling
• External nasal exam
1. Clear rhinorrhea
2. Allergic/transverse crease—a line across the nasal bridge
Anterior Rhinoscopy
• Septum (+/− deviation)
• Inferior turbinates (+/− hypertrophy and edema)
Nasal Endoscopy
• Appearance of the mucosa (pale pink or bluish and “boggy”)
• Presence and quality of any mucus (clear and watery vs thicker)
• If polyps or mucopurulence is noted, consider sinusitis
Allergy Testing
• Skin testing
1. Antigen presented to skin cross-links IgE antibodies on surface of mast cells, resulting in degranulation and formation of a wheal and flare reaction within 15 to 20 minutes.
2. Different forms include skin prick testing and intradermal testing.
3. Sensitivity ~80%
4. Specificity ~80%
5. Performed on volar surfaces of forearms or back
6. Generally safe but does carry a risk of anaphylaxis
7. Relative contraindications:
– Eczema or skin disease at testing site
– Dermatographia
8. Contraindications:
– Pregnancy
– Poorly controlled asthma
– Unstable/severe cardiovascular disease
– Beta-blocker use
9. Certain medications can alter results including the following:
– Oral antihistamines
– Tricyclic antidepressants
– Antipsychotics
– Benzodiazepines
– Omalizumab
– Topical skin corticosteroids
• Serum/specific IgE testing
1. Allergens are bound to a substrate to which serum is added; specific IgE in the serum binds allergens on the substrate; non-human anti-IgE antibodies tagged with a marker are added, and a reaction (radioactive, chemiluminescent, colorimetric, fluorimetric) occurs. The intensity of this reaction is proportional to the amount of specific IgE in the serum.
– Sensitivity 67% to 96%
– Specificity 80% to 100%
– No risk of anaphylaxis
– Not contraindicated in any medical condition
– Not altered by medication use
• Positive test indicates AR.
• Negative test supports non-allergic rhinitis.
Nasal Provocation Testing
• Perform when allergy testing is negative, but concern for IgE mediated process remains high.
• Positive test indicates localized AR.
1. There is on-going debate as to whether localized AR truly exists.
Radiographic Imaging
• Not indicated when history and exam are consistent with AR; use should be limited to atypical presentations or when there is concern for co-occurring chronic rhinosinusitis (CRS).
• The treatment of AR consists of a stepwise process; failure to control symptoms at one step necessitates advancing to the next therapeutic option.
Avoidance and Environmental Controls
• The first step in the treatment of AR
• Can efficiently and effectively reduce allergen exposure and possibly reduce symptoms
• The following environmental controls have been shown to reduce allergen levels
1. Removal of pets
2. Washing pets twice weekly
3. Acaricides (insecticides that kill dust mites)
4. Impermeable covers for bedding
5. Use of high-efficacy particulate air (HEPA) filters
6. Mechanical laundering in hot water
7. Any or all of these controls can be used in combination
Intranasal Steroid Sprays (INS)
• First-line therapy for AR
• Directly modulates pathophysiology of AR
1. Reduce inflammatory mediator and cytokine release
2. Inhibit recruitment of eosinophils, basophils, mononuclear cells, and neutrophils
3. Reduce nasal symptoms of congestion, itching, rhinorrhea and sneezing
4. Reduce eye symptoms of itching, swelling, redness and tearing
• INS shown to be more superior to oral antihistamines (OA) in controlling nasal symptoms
• Once or twice daily dosing
• Can be combined with intranasal antihistamine
Oral Antihistamines (OA)
• Second generation preferred over first generation due to sedating effects of the latter
• Block the action of histamine on the H1 receptor
• Reduce nasal symptoms less effectively than INS
• Reduce eye symptoms as effectively as INS
• Rapid onset of action (advantage over INS)
• Once daily dosing
• Maximum benefit seen with continuous use, however, can be effective on an as-needed basis
Intranasal Antihistamine Sprays (INA)
• Action similar to OA
• Second-line therapy after INS and OA
• Has been shown to reduce rhinorrhea, post-nasal drip, congestion, and sneezing
• More effective at treating nasal congestion than OA
• More rapid onset of action than OA
• Twice daily dosing
• Can be combined with INS
Anti-Leukotrienes (AL)
• Leukotrienes (LTs) are produced from arachidonic acid via the 5-lipoxygenase pathway.
• Cysteinyl leukotrienes are released during both the early and late phase of allergic reactions.
• LTs are pro-inflammatory mediators that facilitate bronchoconstriction, edema, mucus secretion, and vascular permeability.
• ALs are not recommended as a primary therapy in patients with AR.
• Patients with concurrent asthma may benefit from ALs as a first-line therapy.
Combination Therapy
• Appropriate when a patient has failed monotherapy
• Recommended combinations with evidence of efficacy include:
1. INS + INA
2. OA + oral decongestants
Additional Therapeutics
• Oral or topical decongestants
• Guaifenesin (can thin and help clear thick mucus)
• Ipratropium (for persistent watery rhinorrhea)
• Cromolyn (mast cell stabilizer—can be used as a preventative measure prior to exposure)
• Nasal saline
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