Brianna ParkerALLERGIC RHINITIS

OutlineAllergic Rhinitis:1. Signs and Symptoms2. Physical Exam Findings3. Diagnostic Criteria

•Distinguishing Allergic Rhinitis and Alternative Diagnoses

4. Severity Classification•Mild, Moderate, Severe, Intermittent, Persistent

5. Treatment Guidelines• Irritant avoidance, OTC, Prescription

Allergic Rhinitis •Inflammation of the nasal mucosa, occurring when the immune system overreacts to allergens in the air•Signs and symptoms:•Nasal Congestion•Sneezing•Red, itchy, watery eyes•Rhinorrhea

Physical Exam

Findings

•External Nose:• Erythema•Nasal salute

•Nasal mucosa:• Pale, bluish hue• Boggy, swollen turbinates

•Conjunctiva:• Edematous• Cobblestone- appearance

•Eyes:•Dark circles under eyes

Recognizing Allergic Rhinitis• Alternative Diagnosis:

2. Do you have any of the following symptoms?• Symptoms on one side of your nose• Thick, green or yellow discharge• Facial pain• Recurrent nose bleeds• Loss of smell

• Allergic Rhinitis:

1. Do you have any of the following symptoms for at least one hour on most days?•Watery, runny nose• Sneezing•Nasal obstruction•Nasal itching• Conjunctivitis

Diagnostic Guide

• Clinical findings of physical exam• Allergic salute• Allergic shiners• Transverse crease on nose

• Trial of therapy:• Antihistamines• Intranasal corticosteroids

• Allergy testing:• Positive findings on: • Skin IgE testing• Serum allergen specific IgE testing

• Sinonasal Imaging:• Should not be preformed routinely due to

increased risk of radiation

Severity Classifications

Practice Guidelines:First Line Treatment: 

• Avoidance of allergens:• Smoke, chemicals, pets

• Assess for chronic conditions and comorbidities:• Asthma, atopic dermatitis, sleep apnea

First Line Pharmacologic Treatments:

For Mild Intermittent: First line medication:Oral Antihistamine (2nd generation):• Loratadine (Claritin) • Cetirizine (Zyrtec)• Fexofenadine (Allegra)

Benefits: Rapid onset of action, oral administration, relief of symptoms, over-the-counter availability, potential cost saving (generic brand), relief of eye symptoms

Risks, harms, costs: Systemic side effects such as sedation, dry eyes, urinary retention

For Moderate/Severe Intermittent and Persistent: First line medication:Intranasal corticosteroids• Fluticasone (Flonase)• Triamcinolone acetonide (Nasacort)

Benefits: Improved symptom control, improved quality of life, better sleep, targeted local effect

Risks, harms, costs: epistaxis, potential growth concerns in children, septal perforation,  

Differences of opinions: Some believe that this medication should be the first line treatment for all severities of allergic rhinitis while others feel oral antihistamines may be adequate therapy for mild intermmitent patients. 

Additional Pharmacologic Treatments:Intranasal AntihistaminesSecond-line therapy after failure of nasal steroids or oral antihistamines • Benefits: Rapid onset, increased effectiveness for nasal congestion• Risks, harms, costs: Increased cost, sedation, poor taste, more frequent

dosing, epistaxis.• Differences of opinion: Some believe that these should be recommended

at the same level as oral antihistamines, while the majority believe they are second line.

Oral Leukotriene Receptor Antagonists (LTRAs) • Ineffective or less effective therapy at an increased cost; however,

patient’s with dual diagnosis with asthma may benefit from oral LTRAs as a first-line therapy.

Combination Therapy • Combination pharmacologic therapy appropriate when inadequate

response to pharmacologic monotherapy

Alternative Interventions• Immunotherapy• For patients with inadequate response to pharmacologic

therapy 

• Inferior Turbinate Reduction • Surgeon can perform inferior turbinate reduction with nasal

airway turbinate obstruction who have failed medical management.

• Acupuncture

• Herbal Therapy

Questions?

•Global Primary Care Education. (2007). Allergic Rhinitis and its impact on Asthma, p 1-5.

• Ryan, D. (2016). How to identify and manage seasonal allergic rhinitis. Journal Of Community Nursing, 30(2), 54-59 6p.

• Scullion, J., & Holmes, S. (2015). Assessing and treating allergic rhinitis. Practice Nursing, 26(5), 224-230 7p.

References: