Allergic Rhinitis (AR)

Lindsay Kurtz, RN, FNP-S

Integrated Literature Review

• Problem: • Increase in prevalence and multiple associated co-morbidities• Impacts quality of life• Inadequate treatment related to lack of insight on seriousness of condition(Meltzer, Gross, Kafial, & Storms, 2012; Burns, 2012; Holmes & Scullion, 2012; Hadley, Derebery, & Marple,

2012)

• Literature Search:• Databases (CINAHL, Health Source, medscape, ebscoHost, MEDLINE), google

search engine

• Data Evaluation:• Meta-analysis, cochrane reviews, RCTs, and empirical

• Synthesis:• Similarities- atopic triad/atopic march, history taking, method of diagnosis,

treatment plan• Differences- impact on quality of life and severity of diagnosis• Gap- research on efficacy of allergen avoidance

Definition• Chronic atopic (allergic)

condition where expression has hereditary tendency (Boston-Cox, 2012; Burns, 2012; Fitzsimmons, Swan, & Roberts, 2012)

• Rhinitis: diagnosis that affects the lining of the nasal cavity, mucous membranes (Henochowicz & Zieve, 2012)

• Multiple symptoms all involving mucous membranes of the eyes, nose, ears, and throat after exposure to an allergen (Rafiq, 2013)

• Classifications:• Seasonal- outdoor

allergens= pollen, flowers, grasses, weeds, molds, trees

• Perennial- indoor allergens= dust mites, mold, mildew, animal dander, environmental toxins

• Intermittent • Persistent • Occupational- only impacted

at workplace(Boston-Cox, 2012; Burns, 2012;

Fitzsimmons, Swan, & Roberts, 2012; Rafiq, 2013)

Pathophysiology• adfa

Adapted from “Recognizing and managing allergic disease in the community,” by B. Boston-Cox, 2012, British Journal of Community Nursing, 12(7), p.302-308.

• IgE mediated response after exposure to an extrinsic protein causing inflammation of nasal mucosa•IgE mediated response occurs when individual produces IgE antibodies in response to an allergen (Holmes & Scullion, 2012)

• Aeroallergen-driven inflammation of mucous membranes due to the infiltration of and resident inflammatory cells, vasoactive and pro-inflammatory mediators (Rafiq, 2013)

• Histamines and leukotrienes are released (Boston-Cox, 2012)

• Allergic or hypersensitive immunologic response generally occurs in two phases• Early- within minutes of exposure,

high histamine release• Later- 4-6 hours after, mediated by

eosinophils = inflammation(Ahmadifisher, Taghiloo, Esmalizadeh, & Falakaflaki, 2012)

Incidence and Prevalence

• Difficult to pinpoint exact numbers related to ability to self-treat (Burns, 2012)

• Common medical condition impacting at least 40 million people in US (Meltzer, Gross, Kafial, & Storms, 2012)

• Average age of onset = 8-11 years and 80% of cases established by age 20

• Onset usually in first two decades of life, usually not prior to six months and tends to decline with climbing age

• 10-25% of US adults, equal men and women• 9-24% of US children, equal boys and girls• 44-87% of individuals with AR have mixed allergic and non-

allergic rather than a pure form (Rafiq, 2013)

Risk Factors• History of other atopic conditions: asthma, eczema, allergic

conjunctivitis• Family history of atopic diseases (especially if in both

parents)• Pediatrics: chronic nasal obstructions= facial deformities,

dental malocclusions• Pregnancy: physiologic changes may aggravate all types of

rhinitis especially in 2nd trimester• Higher socioeconomic status• Tobacco smoke exposure• Conditions of environment/home

(Meltzer, Gross, Kafial, & Storms, 2012; Burns, 2012; Holmes & Scullion, 2012; Hadley, Derebery, & Marple, 2012; Rafiq, 2013)

Clinical Presentation

(Holmes & Scullion, 2012; Rafiq, 2013; Meltzer, Gross, Kafial, & Storms, 2012; “Is it allergic,” 2012)

• Nasal: • Rhinorrhea, congestion, sneezing,

pruritis, allergic crease

• Sinus: • pressure or congestion

• Conjunctiva:• Watery eyes, redness, pruritis,

allergic shiners

• Ears:• Pressure, pain, inflamed/pale TM,

check for fluid line

• Mouth:• Pruritic palate, dry mucous

membranes (mouth breathers)

• Airway:• Inflammed, erythematous, wheeze

Adapted from “Reducing impact of allergic rhinitis,” by R. Fitzsimons, K. Swan, G. Roberts, 2012, British Journal of School of Nursing, 7(5), p. 231-236.

Diagnosis• Made primary through history and physical (“Allergic rhinitis,” 2007,

Rafiq, 2013)• Symptom diary• Medication trial• Allergy testing

• Critical component of diagnosis is clinical history (Holmes & Scullion, 2012)

• Important not to dismiss or minimize symptoms (Hadley, Derebey, & Marple, 2012)

• ICD-9: • Allergic rhinitis due to pollen 477.0• Allergic rhinitis due to other allergen 477.8• Allergic rhinitis, cause unspecified 477.9

History• Nature, duration, and time course of symptoms

• Any history of “clinical findings” key systems = integumentary, eyes, ears, nose, throat, lymph, respiratory

• Symptoms proximity to triggers• Seasonality, exposures

• Family history of atopic diagnosis• Individual history of asthma, eczema, allergic

conjunctivitis• Individual history of other allergies to foods,

medications hypersensitive immune system( Sicherer & Sher, 2011; Sussman, Sussman, & Sussman, 2010; Rafiq, 2013)

Physical Exam• Look test:

• Allergic salute• Allergic shiners• Allergic crease

• Suggestive, but not specific• Rhinorrhea with clear

mucous• Pale, boggy nasal

mucosa/turbinates• Post-nasal drip • Bilateral rather than

unilateral nasal obstruction

(Holmes & Scullion, 2012, Rafiq, 2013)

http://healthyhappychildren.blogspot.com/2010/04/seasonal-allergies-allergic-salute.html

http://www.drbunn.com/archives/1228

http://www.peds.ufl.edu/peds2/research/debusk/pages/page6_78.html

Differential DiagnosisTypes of Rhinitis

• Non-allergic

• Infectious

• Occupational

• Drug-induced (OCP, ACE, Viagra)

• Hormonal

• Vasomotor (idiopathic)

Non-rhinitis• Skier’s nose- temperature

exposure

• Septal abnormality

• Nasal polyps/tumor

• Pharyngitis

• Sinusitis

• Otitis Media

• Bacterial Conjunctivitis

• Viral URI

• Head trauma- CSF rhinorrhea( Burns, 2012; Boston-Cox, 2012; “Is it allergies,” 2012; Holmes & Scullion, 2012, Rafiq, 2013)

DiagnosticsLabs Skin Testing Imaging

• CBC- elevated eosinophils• Nasal smear- presence of eosinophils• Total serum IgE- elevated

• Allergen prick test/patch test

• CT sinuses- check for complete opacity, fluid level, and mucosal thickening• Rhinoscopy- check anatomical structures

• Labs done prior to referral for skin testing• Imaging: not routine due to cost, radiation exposure, and other tests available (Sicherer & Sher, 2011; Rafiq, 2013)

• Eosinophils = principle effector cells related to the pathophysiology of allergic inflammation•Nasal smears with eosinophilic test = moderately sensitive but highly specific for diagnosis of AR• easy, non-invasive, inexpensive (Ahmadfisher, Taghiloo, Esmailzadeh, & Falakaflaki, 2012)

Red Flags• Presence of other allergic conditions• Sleep disturbance or apnea life threatening?

(Hadley, Derebery, Marple, 2012)• Interference with quality of life? impacting

school, work, or role performance (Holmes & Scullion, 2012)

• Severe anaphylaxis history of this type of allergic reaction, if so to what• If not know the signs and symptoms

Complications• Poorly controlled or untreated AR= huge impact on quality of life

• Nasal Allergy Survey Assessing Limitations (NASAL): first national survey to look at the burden of disease of AR in adults in the US

• Decrease sleep, impaired learning, impaired cognitive functioning, day-time fatigue, and long-term decrease in productivity (Meltzer, Gross, Kafial, & Storms, 2012)

• Uncontrolled can trigger exacerbations of co-morbid conditions: asthma, rhinosinusitis, oropharyngeal lympoid hypertrophy with secondary obstructive sleep apnea, chronic otitis media (Hadley, Derebery, & Marple, 2012)

• Secondary infections: otitis media, sinusitis• Airway hyperreactivity with exposure• Facial changes: especially with mouth breathers(Rafiq, 2013)

Management Plan• 3 steps:

• 1. Allergen avoidance• 2. Medication**if no impact or uncontrolled = refer to an Allergist**• 3. Allergy immunotherapy

• If indicated after further testing• Based on failure of medications, severity of allergies,

associated co-morbidities, any severe allergic reactions

• Education • Follow-up • Support

(“Allergic rhinitis, “2007; Boston-Cox, 2012; Fitzsimons, Swan, & Roberts, 2012; Holmes & Scullion, 2012; Rafiq, 2013)

Non-Pharmacological Treatment

• Limit allergen exposure • Controversial r/t lack of evidence of efficacy• Most benefit if allergen is domestic pet or

occupational• To limit exposure, is there a negative effect

of quality of life?

• Nasal Saline Rinses• Clears airway of secretions and allows for

allergen removal

( Burns, 2012; Boston-Cox, 2012; Henochowicz & Zieve, 2012; Holmes & Scullion, 2012, Rafiq, 2013)

Pharmacological1st Line 2nd Line Immunotherapy

• 2nd Generation Antihistamines: mild-moderate symptoms• Cetirizine,

fexofenadine, loratidine

• AE: mild sedation, mild anitcholinergic effects

•Intranasal Corticosteroids: moderate-severe symptoms• Most effective class

for sx• Flonase, nasonex,

rhinocort• Use after shower or

saline rinse• AE: epistaxis, nasal

septal perforation, systemic

• 1st Generation Antihistamines• Diphenhydramine,

brompheniramine, clemastine

• AE: sedation, prolonged QT, anticholinergic, impaired performance

•Decongestants•Intranasal anticholinergics•Leukotriene antagonists•Mast cells stabilizers

• Based on skin prick test• Injection • Sublingual

( Burns, 2012; Boston-Cox, 2012Holmes & Scullion, 2012, Rafiq, 2013)

Patient Education• Inform about use of symptom diary• Inform of possible necessary environmental adaptation related to

symptom triggers and allergen exposure avoidance• Shower before bed to remove allergens from hair and skin• Stay inside on dry windy days• Keep windows and doors shut• Remove carpeting if possible• Clean frequently to rid of dust mites and molds• Decrease humidity in home with dehumidifier

• Educate about medication selection, dosing, and usage• Review signs and symptoms of anaphylaxis• Encourage to write down questions/concerns to bring to next visit

to help establish a supportive relationship( “Allergies: controlling,” 2011; Burns, 2012; Boston-Cox, 2012; Holmes & Scullion, 2012; “Is it allergic,” 2012; Rafiq, 2013)

Follow-Up• Non-specific restrictions• Avoid allergen exposure

and activities where exposure more likely

• Return for evaluation of management/treatment plan goals, symptom reduction, compliance with medication, improved quality of life

(Burns, 2012; Rafiq, 2013)

Key Points• Atopic triad and atopic march• Allergic shiners, salute, and/or crease• HISTORY and physical fundamental to

diagnosis• Avoidance of known allergens• Intranasal corticosteroids = most effective

treatment of sx in AR• What is the impact on quality of life?

Questions?

ReferencesAhmadifisher, A., Taghiloo, D., Esmailzadeh, A., & Falakaflaki, B. (2012). Nasal eosinophilia as a marker for allergic rhinitis: a

controlled

study of 50 patients. ENT: Ear, Nose, & Throat Journal, 91(3), p.122-124.

Allergies: controlling your symptoms. (2011). American Family Physician, 83(5), p. 620.

Allergic rhinitis. (2007). University of Michigan Health Systems. Retrieved from: http://guidelines.gove/content.aspx?id=11684

Boston-Cox, B. (2012). Recognizing and managing allergic disease in the community. British Journal of Community Nursing, 12(7),

p. 302-308.

Burns, D. (2012). Management of patients with asthma and allergic rhinitis. Nursing Standard, 26(32), P. 41-46.

Fitzsimons, R., Swan, K., & Roberts, G. (2012). Reducing impact of allergic rhinitis. British Journal of School of Nursing, 7(5), p. 231-236.

Hadley, J., Derebery, M., & Marple, B. (2012). Comorbidities and allergic rhinitis: not just a runny nose. Journal of Family Practice,

61(2 suppl), p. S11-5.

Henochowicz, S. & Zieve, D. (Eds.). (2012). Allergic rhinitis: hay fever; nasal allergies. US National Library of Medicine (PubMed Health).

Retrieved from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001816

Holmes, S., & Scullion, J. (2012). Allergic rhinitis: assessment and treatment. Nurse Prescribing, 10(5), p. 222.

Is it allergies or sinus infection?. (2012). Consumer Reports on Health, 24(6), p. 8-9.

Meltzer, E., Gross, G., Kafial, R., & Storms, W. (2012). Allergic rhinitis substantially impacts patient quality of life: findings from

the Nasal Allergy Survey Assessing Limitations. Journal of Family Practice, 61(2 suppl), p. S5-10.

Parle-Peche, S., Powers, L., & St. Anna, L. (2012). Clinical inquiry: intranasal steroids vs. antihistamines: which is better for

seasonal allergies and conjunctivitis?. Journal of Family Practice, 61(6), p. 429-448.

Rafiq, N. (2013). Allergic rhinitis. In F. Domino, et al (Eds.). The 5 Minute Clinical Consult 2013, (p. 1146-1147). Philadelphia:

Wolters Kluwer/ Lippincott Williams and Wilkins.

Sichere, S. & Sher, L. (2011). Diagnosing allergic diseases. Contemporary Pediatrics, 28(8), p. 34-36.

Sussman, G., Sussman, D., & Sussman, A. (2010). Intermittent allergic rhinitis. CMAJ: Canadian Medical Association Journal, 182(9),

p. 935-937.

Woody, J., Wise, S., Koepp, S., & Schloseer, K. (2011). Clinical improvement after escalation of sublingual immunotherapy (SLIT).

ENT: Nose, & Throat Journal, 90(9), p. E16-22.