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 & diagnostic tests

Classification

  • 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

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 & 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 & classify patients based on disease severity, as well as a tool to evaluate symptom control after initiation of treatment strategies by using Information & Communications Technology (ICT) tools & 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 & 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 & 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 & Asthma Test (CARAT)
    • A questionnaire used for the simultaneous daily assessment of disease control of both allergic rhinitis & asthma
  • RhinAsthma Patient Perspective (RAPP)
    • Provides assessment of the QOL of asthma & 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)

Symptom duration of allergic rhinitis is classified into the following:

Intermittent

  • Symptoms occur <4 days/week or symptoms last for <4 consecutive week/year

Persistent

  • Symptoms occur >4 days/week & last for >4 consecutive week/year

Symptom severity of allergic rhinitis is classified into the following:

Mild

  • Normal sleep
  • Normal functioning at work & school
  • Normal conduct of routine & leisure activities
  • No bothersome symptoms

Moderate-Severe

  • Sleep disturbance
  • Problems w/ functioning at work or at school
  • Impairment of routine & leisure activities
  • Bothersome symptoms

Patterns of exposure to allergens:

Seasonal

  • Dependent on a specific season

Perennial

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

Episodic

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

History

  • A family or personal history of allergy & related conditions should be elicited
    • Asthma or eczema
    • Atopic dermatitis
    • Rhinitis
    • Chronic sinusitis
    • Food allergy
    • Drug sensitivity [eg Aspirin/Non-steroidal anti-inflammatory drugs (NSAIDs)]
  • Evaluate for asthma especially in patients diagnosed with severe &/or persistent allergic rhinitis
    • Asthmatic patients most likely (≥80%) suffer from allergic rhinitis
  • Determine onset patterns of symptoms including triggers & seasonality, & relief with certain treatments
  • History of exposure to allergens must be scrutinized
    • Occupational, home & 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 w/ clear, cloudy or colored discharge 
  • Patient should be referred to a specialist if findings are more consistent w/ 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

Laboratory Tests

Allergy Testing

  • Considered as the results would help in the management of the disease
  • Recommend expert referral

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

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

Nasal Smear for Eosinophils

  • Eosinophils may be seen in both allergic & 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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