Breathing Better With Allergic Rhinitis

Allergic Rhinitis (AR) is a common disease affecting children and adults worldwide. Its prevalence is increasing and it is found to have a strong association with asthma and conjunctivitis. The detrimental effects of AR on established asthma and the link between AR and the subsequent development of asthma are well established. It is usually a long standing problem that often goes undetected and frequently treated as Infectious rhinitis, otherwise known as the common cold. Its disease burden is significant – with negative impacts on sleep, mood, social functioning, work/school performance and health-related quality of life. AR has been described as a disease that “may appear quite bearable to the nonsufferer”. There is often a long history of self care using OTC (over the counter) medicines. AR may significantly impact the patient’s quality of life by causing fatigue, headache, cognitive impairment and other systemic symptoms. Sleep disturbances and sedating antihistamine medications can lead to daytime dysfunction. Despite causing a high level of morbidity and health care cost, AR is often considered trivial and not given the importance it deserves, both by patients and health care professionals.

Rhinitis is defined as inflammation of the membranes lining the nose, and is characterized by one or more of the following symptoms-nasal congestion (blocked nose), rhinorrhea (runny nose), sneezing and itching of the nose. Nasal discharge is usually clear and runny. There may be post nasal drip and itchy palate. General debility may manifest as headache and tiredness. Symptoms if persistently unilateral may suggest serious pathology like Polyp or sometimes more serious associations like cancer. Rhinitis is frequently accompanied by symptoms involving the eyes, ears and throat. Allergic conjunctivitis (inflammation of the membrane covering the white part of the eye) is frequently associated with allergic rhinitis and symptoms include redness, tearing and itching of the eyes.

An allergy is the body’s immune reaction to something it deems as harmful. There are three major types of allergies: allergic rhinitis, food allergy and eczema ( skin allergy). In AR our immune system mistakenly identifies a typically harmless substance as an intruder. This substance is called an allergen. The immune system responds to the allergen by releasing histamine and chemical mediators that typically cause symptoms in the nose. AR is most often caused by pollen carried in the air. Common indoor allergens include animal dander, mold, droppings from dust mites and cockroach particles. Outdoor allergens include grass pollen, tree pollen, weed pollen and mold spores. Initially AR was categorized as seasonal (occurs during a specific season) or perennial (occurs throughout the year). However, patients with multiple “seasonal” allergies may have symptoms throughout most of the year. Therefore, AR is now classified according to symptom duration (intermittent or persistent) and severity (mild, moderate or severe). Symptoms similar to AR may also occur from irritants such as smoke, fragrance (perfumes/ colognes) and strong odors. This is nonallergic rhinitis triggered by irritants and not allergens.

AR is primarily diagnosed on the basis of history, with physical examination providing additional clues. Nasal pruritus (itching) may stimulate grimacing and twitching and picking of the nose. The latter may result in Epistaxis (bleeding from nose). Children often have the allergic salute, an upward rubbing of the nose with the palm of the hand. This often produces an allergic nasal crease, an accentuated, horizontal skin fold over the lower third of the nose. Children with AR may also  have recurrent sinusitis or otitis media (middle ear inflammation), eczema, or asthma. AR patients, particularly children with significant nasal obstruction and venous congestion, may also demonstrate edema and darkening of the tissues beneath the eyes called “shiners”. Diagnostic tests include skin prick test and blood test to check immunoglobulin (IgE) antibody. A unique condition is local allergic rhinitis, which is characterized by local IgE production in the nasal tissues while systemic allergy testing is negative.

Primary step in the management of AR is avoidance of allergen. This is however not always possible. Medications commonly used include antihistamines, decongestants and corticosteroids that are administered intranasally or orally. Drugs called Leukotriene Receptor Antagonist are showing good results in controlling AR. These are used alone as well as in combination with antihistamines. Immunotherapy, also known as hyposensitisation or desensitisation, involves gradually introducing more and more of the allergen into our body to make our immune system less sensitive to it. It is in the form of allergy shots or sublingual tablets. This form of treatment, recommended if pharmacologic therapy for AR is not effective or is not tolerated, has to be taken under specialists in allergy. Surgery is only very rarely needed for AR. Surgery with/without turbinate  reduction is needed to allow access to the nose for more effective use of sprays or to open the sinuses in patients insufficiently responsive to medical treatment because of structural problems.

Avoidance of allergen is difficult but multiple measures to reduce exposure can be effective. During peak pollen season, the following steps are advisable- putting on masks, sunglasses and hats to keep pollen allergens out of eyes and face, washing hair and changing clothes after reaching home, windows to be kept closed during the early  mornings and evenings to prevent pollen entry and avoid drying clothes/ linen outside . Pets should not be kept inside or otherwise limited to one room, preferably one without a carpet. Measures against house dust mites include – regular cleaning of soft toys, soft furnishings and carpets, using a vacuum cleaner with a HEPA filter, using a damp cloth to wipe dusty surfaces and frequently washing pillows and bedsheets. Mold spores can be dealt by using exhaust fans that vent outside our home in the kitchen and bathroom and fix any leak in the roof, walls or plumbing so that mold does not have moisture to grow.

The symptoms of AR occasionally improve with time but it’s unlikely that it will disappear completely. Accurate and early diagnosis is important for effective control of AR in children and awareness of parents and caregivers about the symptoms of AR helps in seeking early medical attention. AR may interrupt night time sleep , cause daytime sleepiness, school absenteeism, mood swings and adversely affect academic performance.  As nose is the gateway to the respiratory tract it is necessary that AR be diagnosed accurately and controlled effectively. 

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