rhinitis%20-%20allergic
RHINITIS - ALLERGIC
Allergic rhinitis is a symptomatic disorder of the nose secondary to IgE-mediated inflammation of the nasal membranes induced after exposure to allergens.
Major symptoms include nasal itching, watery rhinorrhea, nasal obstruction/congestion, sneezing and postnasal drainage.
Other symptoms include headache, conjunctival symptoms, eye pruritus, impaired smell and morning cough.
Symptoms can reverse spontaneous w/ or w/o treatment.

Diagnosis

  • The diagnosis of allergic rhinitis relies mainly on the clinical history, physical exam and diagnostic tests

Classification

Classification Based on Pathology:

  • Infection
    • Acute
    • Chronic
  • Irritant rhinitis
    • Physical
    • Chemical
    • Radiation
  • Hyperesthetic non-infectious rhinitis
    • Combined type (nasal hypersensitivity)
      • Allergic (perennial, seasonal)
      • Nonallergic (vasomotor or idiopathic rhinitis, rhinitis with eosinophilia syndrome)
      • Rhinorrhea type (gustatory rhinitis, cold inhalation rhinitis, senile rhinitis)
      • Congestive type (medicament rhinitis, psychogenic rhinitis, pregnant rhinopathia, hormonal rhinitis and cold rhinitis)
  • Others
    • Atopic rhinitis
    • Specific granulomatous rhinitis

Classification According to Frequency or Duration of Symptoms:

  • Intermittent: Symptoms occur <4 days/week or <4 weeks/year
  • Persistent: Symptoms occur >4 days/week and >4 weeks/year

Classification According to Severity of Symptoms:

  • Mild: Symptoms do not interfere with quality of life as manifested by normal sleep, ability to perform normal daily activities, sport and leisure, normal performance at work or in school and without troublesome symptoms
  • Moderate-severe: Symptoms interfere with quality of life as manifested by 1 or more of the following:
    • Impaired daily activities, leisure, and/or sport activities
    • Impaired school or work performance
    • Sleep disturbance
    • Troublesome symptoms

Evaluation

Assessment of Disease Control
  • The following factors are considered when evaluating a patient’s response to treatment:
    • Symptom score
    • Visual analogue scales (VAS)
    • Measures of nasal obstruction (eg peak nasal inspiratory flow, acoustic rhinometry, rhinomanometry)
    • Allergic Rhinitis and its Impact on Asthma (ARIA) severity classification
    • Quality of Life (QOL) result
    • Itemized scoring
    • Symptom-medication scoring
MACVIA-ARIA Sentinel NetworK for Allergic Rhinitis (MASK-Rhinitis)
  • A clinical approach used to diagnose and classify patients based on disease severity, as well as a tool to evaluate symptom control after initiation of treatment strategies by using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS), based on ARIA guidelines
  • Suggests that everyday monitoring with VAS can potentially help a patient to take control of symptoms
Visual Analogue Scales (VAS)
  • An electronic-based tool used to monitor the course of allergic rhinitis especially the effectiveness of therapy
  • It is used everyday for better symptom control
  • A low VAS measurement with the establishment of treatment, shows an amount of improvement, as indicated in Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) as well as in terms of work efficiency
    • VAS score of 2 or <10 means well-controlled allergic rhinitis
  • A high VAS measurement (>50 mm) shows no effect in symptom relief
Electronic Evaluation of Allergic Conditions
  • E-allergy screening
    • An online procedure consisting of questionnaires for early detection of the presence of allergy and asthma
    • Results are based on the calculated risk for certain allergic conditions (eg allergic rhinitis, asthma, atopic dermatitis, insect allergies)
    • Used as support for an allergic disease diagnosis and should not replace a physician’s evaluation
  • MASK Aerobiology
    • An IOS/Android app that is VAS-patterned which measures control of rhinitis
  • Control of Allergic Rhinitis and Asthma Test (CARAT)
    • A questionnaire used for the simultaneous daily assessment of disease control of both allergic rhinitis and asthma
  • RhinAsthma Patient Perspective (RAPP)
    • Provides assessment of the QOL of asthma and rhinitis patients in relation to health issues by means of a questionnaire
    • The score is the sum of the answers for the 8 questions provided
      • 8: No effect on QOL
      • 40: With heavy effect on QOL
Clinical Decision Support Systems (CDSS)
  • A technology-based tool that helps in monitoring control of the disease to be able to formulate an efficient medical management plan
  • Should consist of quality guidelines or algorithms that would help in deciding whether a step-up or a step-down in the treatment is necessary
  • Suggests a standard guide for therapy that is based on a physician’s view during clinic visits prior to the pollen season
  • Used in combination with e-allergy screening, MASK aerobiology or CARAT

Assessment

  • Assessment will be based on the following:
    • Patient's symptomatology
    • Patient's exposure to allergens
    • Visual analogue scales (VAS)
  • Assess pattern of symptoms: (See classification based on frequency and severity of symptoms)
    • Mild intermittent allergic rhinitis
    • Moderate-severe intermittent allergic rhinitis
    • Mild persistent allergic rhinitis
    • Moderate-severe persistent allergic rhinitis

Patterns of exposure to allergens:

Seasonal

  • Dependent on a specific season

Perennial

  • Year-round allergen exposure and usually present in everyday environment

Episodic

  • Patient is exposed to allergens not normally encountered in daily activities

Visual Analogue Scales (VAS)

  • A psychometric response scale for subjective characteristics or attitudes of disease-related symptom severity in each patient that is used to classify symptom severity and disease control
  • VAS score of 50 mm suggests moderate-severe allergic rhinitis

History

  • A family or personal history of allergy and related conditions should be elicited
    • Asthma or eczema
    • Atopic dermatitis
    • Rhinitis
    • Chronic sinusitis
    • Food allergy
    • Drug sensitivity [eg Aspirin/Nonsteroidal anti-inflammatory drugs (NSAIDs)]
  • Evaluate for asthma especially in patients diagnosed with severe and/or persistent allergic rhinitis
    • Asthmatic patients most likely (≥80%) suffer from allergic rhinitis
  • Determine onset patterns of symptoms including triggers and seasonality, and relief with certain treatments
  • History of exposure to allergens must be scrutinized
    • Occupational, home and school exposures
    • Exposure to passive or active smoking

Physical Examination

  • Complete examination of all systems potentially affected by allergies should be performed in patients with history of rhinitis

Nasal Examination

  • Preferably through endoscopy performed by specialist
  • May reveal the following:
    • Swollen nasal turbinates
    • Rhinorrhea with clear, watery, cloudy or colored discharge; colored discharge may indicate a comorbid condition with allergic rhinitis 
  • Patient should be referred to a specialist if findings are more consistent with a structural etiology than rhinitis (eg tumors, nasal polyps, septal deviation)

Other physical findings include:

  • Conjunctivitis
  • Allergic “shiners” (dark circles under the eyes resulting from venous stasis)
  • Lower eyelid creases
  • Nasal crease
  • Periorbital edema
  • Cobblestoning of the pharynx
    • Some patients may present with geographic tongue

Laboratory Tests

Allergy Testing

  • Considered as the results would help in the management of the disease and identification of allergen to facilitate avoidance
  • Recommend expert referral

Skin Tests and Radioallergosorbent Test (RAST)/Automated Immunoassay Systems

  • Used to differentiate allergic from nonallergic rhinitis or to determine specific causative allergens
  • Skin test is preferred due to its better sensitivity, faster results, and lesser cost

Nasal Smear for Eosinophils

  • Eosinophils may be seen in both allergic and nonallergic rhinitis
  • Presence of eosinophilia predicts a good response to topical nasal corticosteroid medication
  • May be performed when allergic symptoms are present
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