Rhinitis -combination of sneezing, discharge and blocking lasting >1 hour on most days

Prevalence of Rhinitis Affects 25% of the population Allergic rhinitis is the commonest allergic disorder in Primary Care Co-morbidity with asthma “One airway, one disease”

Impact of rhinitis Loss of sleep Social embarrassment Poor performance and concentration Loss of productivity at work, hence economic implications Learning difficulties at school

History Purulent or non purulent Unilateral from bilateral Seasonal (intermittent) and perennial (persistent) Social and environmental factors Asthma and dermatitis - atopy Trigger factors and non-specific irritants

Symptoms in allergic rhinitis IntermittentPersistent SneezingAlwaysVariable Eye symptomsCommonRare Blocked noseVariableAlways Nasal secretionCommonVariable Disturbed smellVariableCommon AsthmaVariableCommon

Aeroallergens Grass pollen Tree pollens esp. Birch House Dust Mite Dog, Cat and other furry animals Nettles Moulds

Key points Reactions to NSAIDS and Aspirin especially with polyps Allergic versus non allergic - history + SPT Food allergy is a very rare cause of isolated rhinitis

Examination Face - allergic salute and nasal crease, dark circles around eyes Rhinoscopy/endoscopy -polyp or turbinate? nasal patency? Exclude other mechanical factors - foreign body Skin prick tests and RAST Imaging

Miscellaneous causes of rhinitis Idiopathic Rhinitis medicamentosa (decongestants) Cocaine abuse Hormonal - Oral contraceptives, Pregnancy and Hypothyroidism Antihypertensives- ACE inhibitors,  Blockers, Other drugs - Chlorpromazine and aspirin Wegeners Granulomatosis Cystic fibrosis/CSF leak

Non specific irritants - precipitate or aggravate Cold air Dust Fumes Paint Polluted air Washing powder Hot spicy food Alcoholic beverages Printing ink Rape odour

Pollen avoidance measures! Pollen count max late pm Sleep with windows closed Excuse not to mow the lawn Keep car windows closed - consider a filter Wear sunglasses Holiday in costal areas Listen out for pollen count forecasts

Allergen avoidance in Perennial Rhinitis Animal dander No pets Wash pets Keep pets outside Thorough vacuuming Sensitisation to cat without direct exposure to cats! Clin Exp Allergy 1999:29; House dust mite No carpets No furry toys Encasement bedding Increase ventilation Hot wash bed linen Vacuum regularly Feather pillows OK Freeze cuddly toys Damp dust

Avoidance ? Possible In UK – 95% time spent indoors –95% wall to wall carpets –16 million cats and dogs versus 10 million children –high prevalence of allergens in public place

Drug Treatment Antihistamines Intra-nasal corticosteroid sprays Cromoglycate and nedocromil Nasal decongestants (1 week max.) Oral steroids NOT depo-steroids Desensitisation - grass pollen, cat and HDM route of administration - sc/sublingual Anti IgE therapy

Any place for depot triamcinolone in hayfever? Drugs and Therapeutics Bulletin 1999:37:3;17-18 Depot corticosteroid treatment for hay fever causing avascular necrosis of both hips. Nasser and Ewan BMJ 2001:322;