Allergic rhinitis

Background

Inflammation associated with allergic rhinitis.

• Also called hay fever - inflammation of the nasal mucosa secondary to allergens in the air.
• Associated with asthma and atopic dermatitis

Clinical Features

• Constellation of symptoms:
  • Thin, clear rhinorrhea (if thick or discolored, consider infectious causes)
  • Sneezing, itching of the nose
  • Nasal congestion and/or obstruction
  • Clogged feeling in the ears
• Common triggers:
  • Animals
  • Environmental (e.g. grassess, pollens); often symptomatic with seasonal changes
• Symptoms last until triggers are removed
• Should not have actual fever

Differential Diagnosis

Rhinorrhea

• Upper respiratory infection, influenza
• Sinusitis
• Juvenile nasopharyngeal angiofibroma
• Nasal polyp
• Nasal mass
• Nasal foreign body
• CSF leak (e.g. basilar skull fracture)
• Toxic inhalation (e.g. selenium toxicity, neurotoxic shellfish poisoning)

Evaluation

• Clinical diagnosis
  • PE may show infraorbital edema and darkening (allergic shiner), transverse nasal crease (allergic salute), and cobble-stoning of the posterior oropharynx
• Rule out bacterial infection

Management

• Reduce exposure to allergen
  • If environmental, sleep with windows closed, change clothes and/or shower when returning home after being outdoors
• Saline nasal irrigation (neti pot) twice a day- washes out allergens
• Combination of topic nasal steroids (fluticasone propionate, nasonex) and/or nasal antihistamines (patanase)
  • Must be used for several weeks before symptomatic relief is realized

Disposition

• Discharge home
  • Consider allergist referral if nasal sprays not helping
  • Consider ENT referral to evaluate for the need for sinus surgery, which may be help by opening up the sinuses allowing for better distribution of topical medications