Rhinitis, Allergic
Rhinitis, Allergic: Excerpt from The 5-Minute Pediatric Consult
Esther K. Chung, MD, MPH
Karen P. Zimmer, MD, MPH
Rhinitis, Allergic - BASICS
Rhinitis, Allergic - description
- Inflammation of the nasal and sinus mucosa, associated with sneezing, swelling, increased mucus production, and nasal obstruction. May be classified as seasonal, perennial, or a combination
- Seasonal: Periodic symptoms, involving the same season for at least 2 consecutive years; most often due to pollens (e.g., trees, grass, weeds) and outdoor spores
- Perennial: Occurring at least 9 months of the year; may be more difficult to detect because of overlap with other infections; may be due to multiple seasonal allergies or continual exposure to allergens (such as dust mites, cockroaches, molds, and animal dander)
- Perennial with seasonal exacerbations
Rhinitis, Allergic - general prevention
- Minimize exposure to dust mites: Consider removing carpets, upholstered furniture, and curtains; washing bedding in hot water frequently, at least every 1–2 weeks; using pillow and mattress covers.
- Minimize exposure to animal dander: Minimize exposure to all animals; consider using solutions containing tannic acid, which will denature animal allergens; shampoo pets frequently if pets cannot be removed from the household; use air-vent filters.
- Minimize exposure to pollens: Keep windows closed, use air conditioning, and avoid leaf raking or lawn mowing.
- Minimize exposure to molds: Keep houseplants out of the bedroom; avoid spending time in the basement, keep humidity at 35–50%.
Rhinitis, Allergic - epidemiology
Rhinitis, Allergic - prevalence
- Increasing prevalence
- Most common allergic disease, affecting ~40 million Americans; affects 40% of children and 15–30% of adolescents
- Boys affected more than girls in childhood; equal rates among men and women
Rhinitis, Allergic - risk factors
Rhinitis, Allergic - genetics
- Increased incidence in families with atopic disease
- If 1 parent has allergies, each child has a 30% chance of having an allergy; if both parents have allergies, each child has a 70% chance of having an allergy.
Rhinitis, Allergic - etiology
- Indoor allergens: House dust mite, cockroaches, animal dander, cigarette smoke, hair spray, paint, molds
- Pollens: Tree pollens in early spring, grass in late spring and early summer, ragweed in late summer and autumn
- Multiple environmental factors
- Changes in air temperature
Rhinitis, Allergic - associated conditions
- Asthma
- Allergic conjunctivitis
- Atopic dermatitis (eczema)
- Urticaria
- Otitis media with effusion
- Sleep, taste, and/or smell disturbance
- Nasal polyps
- Mouth breathing
- Snoring
- Adenoidal hypertrophy and sleep apnea
- Decreased appetite
- Delayed speech
Rhinitis, Allergic - DIAGNOSIS
Rhinitis, Allergic - signs & symptoms
Rhinitis, Allergic - history
- What are typical symptoms? Patient often reports stuffy nose, sneezing, itching, runny nose, noisy breathing, snoring, cough, halitosis, and repeated throat clearing. Sensation of plugged ears and wheezing may occur.
- Are eyes red and itchy? Suggestive of allergic conjunctivitis
- Are symptoms seasonal, perennial, or episodic? May help to identify potential allergens
- Any exacerbating factors, including pollen, animals, cigarette smoke, dust, molds? Useful information to prevent symptoms from occurring
- Is there a family history of atopic disease, such as asthma or atopic dermatitis? Supports the diagnosis
- Any related illnesses? Asthma, urticaria, eczema, ear infections, and delayed speech are commonly associated conditions.
Rhinitis, Allergic - physical exam
- Allergic shiners: Dark discoloration beneath the eyes due to obstruction of lymphatic and venous drainage, chronic nasal obstruction, and suborbital edema
- Dennie–Morgan lines: Creases in the lower eyelid radiating outward from the inner canthus; caused by spasm in the muscles of Müller around the eye due to chronic congestion and stasis of blood
- Allergic salute: A gesture characterized by rubbing the nose with the palm of the hand upward to decrease itching and temporarily open the nasal passages
- Allergic crease: Transverse crease near the tip of the nose, secondary to rubbing
- Nasal mucosa may appear pale and/or edematous; mucoid or watery material may be seen in the nasal cavity; check for nasal polyps, septal deviation.
Rhinitis, Allergic - tests
- Audiometry and tympanometry when indicated
- Sweat test if cystic fibrosis is suspected or if nasal polyps are present
Rhinitis, Allergic - lab
- Nasal cytology
- Specimen of nasal discharge to check for the presence of eosinophils. Have the patient blow his or her nose into a piece of nonporous paper or collect discharge with a cotton swab and transfer the discharge to a glass slide. >10% eosinophils are considered positive for nasal eosinophilia. Note: Use of intranasal steroids may reduce the number of eosinophils found in nasal discharge.
- RAST (radioallergosorbent tests):
- In vitro test to measure allergen-specific IgE; expensive; useful in patients who have diffuse atopic dermatitis. The ImmunoCAP system (Pharmacia Diagnostics) is the preferred method for specific IgE testing; uses a single blood sample to identify levels of specific IgE to a number of common respiratory allergens (available as a profile specific to the region of the country where the patient resides), food antigens (food allergy profile), or both (childhood allergy profile).
- Total IgE: Elevated in allergic rhinitis; not routinely indicated, but may come as part of specific IgE testing; >100 kU/L is considered elevated.
- CBC: May show eosinophilia; not routinely indicated
- Skin testing:
- Prick test: Percutaneous, qualitative test in which antigen concentrate is placed on the skin of the volar surface of the arm or upper back, and a needle is inserted; the skin reaction is graded subjectively from 0–4.
- Intradermal test: Qualitative test in which antigen is introduced intradermally (0.02 mL with a 26–30-gauge needle); more sensitive than the prick test and often used if prick test is negative or equivocal; the degree of swelling and erythema is graded from 0–4.
- Caution: Skin tests may be difficult to interpret in patients with diffuse eczema and dermatographism.
Rhinitis, Allergic - diag proced-surgery
Rhinoscopy to assess the nasal turbinates and to look for nasal polyps
Rhinitis, Allergic - differencial diagnosis
- Infection:
- Viral upper respiratory tract infection
- Bacterial sinusitis
- Environmental:
- Foreign body
- Temperature
- Odors
- Tumors:
- Nasal polyps
- Dermoid cyst
- Nasal glioma
- Congenital:
- Cystic fibrosis
- Choanal atresia
- Immotile cilia syndrome
- Septal deviation
- Primary atrophic rhinitis
- Immunologic:
- Sarcoidosis
- Wegener granulomatosis
- Systemic lupus erythematosus
- Sjögren syndrome
- Miscellaneous:
- Idiopathic (vasomotor) rhinitis
- Nonallergic perennial rhinitis
- Rhinitis medicamentosa
- Rhinitis associated with pregnancy/other hormonal rhinitis
- Hypothyroidism
- Idiopathic neonatal rhinitis
- Drug-induced rhinitis
- Food-induced rhinitis
Rhinitis, Allergic - TREATMENT
Rhinitis, Allergic - general measures
Avoidance therapy: Identify and eliminate known/suspected allergens.
Rhinitis, Allergic - medication
- Caution: Cardiac arrhythmias have been seen with patients taking terfenadine and astemizole.
- Mucolytics: Act to thin the mucus and thereby improve mucociliary flow:
- Steam inhalation
- Normal saline drops
- Bicarbonate spray
- N-acetylcysteine (orally or inhaled)
- Oral guaifenesin
- Antihistamines: Competitively blocking histamine 1 (H2nd-generation antihistamines: Tend not to cross the blood–brain barrier and therefore do not have CNS side effects such as drowsiness
- Loratadine (Claritin, Schering): FDA–approved for children as young as 2 years of age. Dose: Ages 2–5 years, 5 mg PO daily; ages 6 years or older, 10 mg PO daily
- Cetirizine HCl (Zyrtec, Pfizer): FDA-approved for children as young as 6 months of age. Dose: Age 6 months to 5 years, 2.5 mg = 1/2 tsp (1 mg/mL banana–grape flavored syrup) PO daily with maximum dose of 5 mg/d (must be divided into 2.5 mg b.i.d. for children <2 years of age). Age 6 years and over, 5–10 mg daily
- Fexofenadine (Allegra, Aventis): Age 6–11 years: 30-mg tab b.i.d.; age ≥12 years, 60 mg b.i.d. or 180 mg daily.
- Intranasal 2nd-generation antihistamine: Azelastine: Age 5–11 years; 137 mcg; 1 spray per nostril bid. The efficacy of this dose has not yet been established in the pediatric population but rather extrapolated from adult data.
- 1st-generation antihistamine side effects include drowsiness, performance impairment, and paradoxical excitement; anticholinergic side effects (e.g., dry mouth, tachycardia, urinary retention, and constipation): Diphenhydramine (Benadryl) 5 mg/kg/d divided q.i.d.
Intranasal steroids: Blunt early-phase reactions and block late-phase reactions; may not be fully effective until several days to 2 weeks after initiation of therapy. Must be used regularly and best when administered lying down with the head back
- Beclomethasone (Vancenase, Beconase): For use in children ≥6 years of age
- Flunisolide (Aerobid): For use in children ≥6 years of age
- Fluticasone propionate (Flonase 0.05%): For use in children ≥4 years of age
- Budesonide (Rhinocort): For use in children ≥6 years of age
- Triamcinolone acetonide (Nasacort): For use in children ≥6 years of age
- Mometasone furoate monohydrate (Nasonex): For use in children ≥2 years of age
Topical cromolyn (Nasalcrom): Mast-cell stabilizer; minimal side effects; does not provide immediate relief (may take 2–4 weeks to see clinical effect): For use in children ≥2 years of age
Oral decongestants: αTopical decongestants: Sympathomimetics such as short-acting phenylephrine (Neo-Synephrine) and long-acting oxymetazoline (Afrin) may be useful for a few days to open nasal passages to allow for delivery of topical steroids; side effects include drying of the mucosa and burning. Use for more than a few (3–5) days may result in rebound vasodilatation and congestion (rhinitis medicamentosa).
Combined oral decongestants and antihistamines: Numerous preparations on the market
Immunotherapy: Also referred to as hyposensitization or desensitization. Consists of a series of injections with specific allergens, with increasing concentrations of allergens, once or twice weekly. Recommended for patients who have not responded to pharmacologic therapy:
- Extremely effective and long lasting. After several months to years of treatment, total serum IgE levels decrease, and the intensity of the early-phase response is reduced.
- Side effects include urticaria, bronchospasm, hypotension, and anaphylaxis.
Rhinitis, Allergic - surgery
- Removal of allergic polyps
- Inferior turbinate surgery to reduce the size of the turbinate and relieve obstruction
- Endoscopic sinus surgery to relieve obstruction
Rhinitis, Allergic - FOLLOW UP
Rhinitis, Allergic - prognosis
Generally good: Complete recovery occurs in 5–10% of patients.
Rhinitis, Allergic - complications
- Chronic sinusitis
- Recurrent otitis media
- Hoarseness
- Loss of smell
- Loss of hearing
- High-arched palate and dental malocclusion from chronic mouth breathing
Rhinitis, Allergic - patient monitoring
Watch for fever, prolonged or severe headache, dizziness, pain, or purulent discharge; should suggest a diagnosis other than allergic rhinitis alone
Rhinitis, Allergic - bibliography
- Berger WE. Pediatric allergic rhinitis: Antihistamine selection. Clin Pediatr. 2005;44:655–664.
- Bousquet J, Van Cauwenberge P, Khaltaev N; Aria Workshop Group, World Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(5 Suppl):S147–S334.
- Kaari J. The role of intranasal corticosteroids in the management of pediatric allergic rhinitis. Clin Pediatr. 2006;45:697–704.
- Mahr TA, Ketan S. Update on allergic rhinitis. Pediatr Rev. 2005;26:284–288.
- Prenner BM, Schenkel E. Allergic rhinitis: Treatment based on patient profiles. Am J Med. 2006;119:230–237.
Rhinitis, Allergic - CODES
Rhinitis, Allergic - icd9
477.9 Allergic rhinitis
Rhinitis, Allergic - FAQ
- Q: How does one minimize exposure to dust mites?
- A: Keep household temperature low; maintain humidity at ~40–50%; wash linens weekly at hot temperatures; use a microfilter when vacuuming; place mattress and box spring in tightly woven casing; use air conditioning; use high-efficiency particulate air filter units.
- Q: How often are nasal polyps associated with cystic fibrosis?
- A: In up to 40% of children, nasal polyps are associated with cystic fibrosis. <0.5% of children with asthma and rhinitis have nasal polyps.
- Q: When used on a daily basis, are intranasal steroids safe?
- A: Yes. It is generally accepted that inhaled steroids are safe. Growth suppression has been reported in children using certain intranasal steroids; however, this effect does not appear to be an effect of all intranasal steroids. Importantly, one should use the lowest effective dose of intranasal steroids when treating allergic rhinitis.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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