Under-recognized, particularly when chronic blockage (without itch/sneezing) rather than sneeze/discharge. Late phase reactions involving Eosinphil induction by T cells tends to produce chronic swelling and non-specific irritability eg cold air. Nose problems impact with everything connected eg eyes, sinuses, middle ear, lungs. Differential is wide eg CF/PCD, deviated septum, polyps.
Considered trivial, and indeed work and school attendance not much affected but quality of work much more so – proven sleep problems, tiredness, impaired cognitive function. In a study of UK 15-17yr olds , students who dropped a grade between prelims and finals were significantly more likely to have had allergic rhinitis symptoms, to have taken antihistamines, and in particular, Piriton (OR=1.7). 43% increased odds of dropping an exam grade, goes up to 71% if using a sedating antihistamine [Samantha Walker, JACI 2007: 120; 381-387]
In asthma, prevalence of rhinitis increases over time to very high levels. If significant symptoms then OR=4 for poor asthma control (equivalent to poor inhaler technique!), plus combination of acute rhinitis and URTI gives OR=20 for asthma exacerbation.
Persistent defined as more than 4/7 per week, for more than 4/52. Mod/severe defined as any impairment of sleep or activity, else “troublesome symptoms” (BSACI includes seasonal or not, where you might be considering immunotherapy).
On examination (with auroscope), blue boggy wet mucosa, ?nasal crease.
SPT is pretty good at finding causes – depends how many you screen for, of course! In a US study, 65% of patients (mixed adults/children) had a positive: house dust mite (HDM) most commonly, else trees, weeds, moulds. Aspergillus and Penicillium are indoor moulds, Alternaria is outdoors. Cat allergens are commonly found in homes without cats! Nasal challenge can be done if neg SPT/IgE (Rondon, Curr Op Allerg Clin Imm 2010).
See also hay fever.
Treatment
Children/adults same, just watch for doses/side effects.
Intranasal steroids most effective. Antihistamines, both intranasal and oral, are effective. Consider also leukotriene receptor antagonist (LRTA) eg montelukast (esp if co-existing asthma). Oral decongestants and steroids are also used short term sometimes.
For intermittent symptoms or mild persistent, no preferred treatment option – intranasal antihistamine, oral antihistamine, decongestant, LTRA, or combination. Nasal saline douches eg Sterimar have some evidence for efficacy, also nasal filters (not caught on yet!).
If co-existing conjunctivitis, prob best to go straight to nasal steroid, else add oral/topical antihistamine, or topical cromone, or saline.
Oral decongestant should only be used for max 10/7, can be useful diagnostically. Similarly oral steroids, if poor response or where diagnosis still unsure.
Cromoglycate (Rynacrom) has a role in young children but prob less effective than topical steroid or anthistamine, and at 4-6x a day, certainly less convenient.
Nasal ipratroprium recommended for rhinorrhoea.
Azelastine spray (Rhinolast) has been discontinued, so only nasal antihistamine is now the combination product Dymista (with flutic, from age 12). Not as good as steroid, doesn’t seem to have much effect on congestion (prob non-type 1 mechanism). Bad taste, irritation.
Montelukast licensed for rhinitis in asthmatics where resistant to other treatments, from age 15! ARIA recommend for over 6.
Intranasal steroids superior to top/systemic antihistamine, LRTA (even combinations). They also help eye symptoms, whereas nasal antihistamines don’t. Beclometasone (from age 6yr) and budesonide have relatively high bioavailability so better to use fluticasone (from age 4, furoate or propionate) or mometasone (from age 6), esp if other steroid use eg for asthma/eczema.Technique is often an issue – most gets sprayed or sniffed into back of throat!
Nasal spray Technique – (see video) Shake, head slightly forward, aim at ceiling (better to use opposite hand?), don’t sniff. Gargle and spit if taste unpleasant. Keep with toothbrush or other marker of habitual routine.
See also immunotherapy – some evidence that immunotherapy for rhinitis reduces risk of asthma!