Allergic Rhinitis Jillian La Monte RN

Definition of Problem Rhinitis (coryza) is an inflammation of the nasal mucosa characterized by nasal congestion, rhinorrhea, sneezing, pruritus, and/or postnasal drainage. Its etiology is varied, but in general, it is categorized as either allergic or nonallergic rhinitis. It may be acute or chronic, but the most common forms are viral rhinitis and perennial or seasonal (“hay fever”) allergic rhinitis. (Dunphy, Winland-Brown, Porter, & Thomas, 2011).

Pathophysiology Allergic rhinitis involves inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx. The nose invariably is involved, and the other organs are affected in certain individuals. Inflammation of the mucous membranes is characterized by a complex interaction of inflammatory mediators but ultimately is triggered by an immunoglobulin E (IgE)–mediated response to an extrinsic protein, (Sheikh, 2014).

Types of Rhinitis Seasonal: Symptoms of seasonal allergic rhinitis occur in spring, summer and/or early fall. They are usually caused by allergic sensitivity to pollens from trees, grasses or weeds, or to airborne mold spores. Perennial: People with perennial allergic rhinitis experience symptoms year-round. It is generally caused by sensitivity to house dust mites, animal dander, cockroaches and/or mold spores. Underlying or hidden food allergies rarely cause perennial nasal symptoms. Allergic rhinitis can take on different forms which include seasonal or perennial. These then can either be persistent or intermittent.

Epidemiology Onset occurs within the first two decades, rarely before 6 months of age. Mean age of onset 8-11 years of age. ~10-25% of the US adult population and 9-42% of the US pediatric population are affected. (Rafiq, 2014)

Risk Factors Family History Higher socioeconomic status Tobacco smoke Genetic Higher socioeconomic status Tobacco smoke Asthma Pets in the house (Rafiq, 2014) Complex but strong genetic predilection present (80% have family history of allergic disorders)

Clinical Findings Dark circles under eyes, “allergic shiners” Transverse nasal crease from rubbing nose upward; typically seen in children Rhinorrhea, usually with clear discharge Pale, boggy, blue-gray nasal mucosa Postnasal mucus discharge Oropharyngeal lymphoid tissue hypertrophy (Rafiq, 2014) When a diagnosis is made for allergic rhinitis it is typically made by taking a History. Nose – Watery nasal discharge, blocked nasal passages, sneezing, nasal itching, postnasal drip, loss of taste, facial pressure or pain. ●Eyes – Itchy, red eyes, feeling of grittiness in the eyes, swelling and blueness of the skin below the eyes (called allergic shiners). (See "Patient information: Allergic conjunctivitis (Beyond the Basics)".) ●Throat and ears – Sore throat, hoarse voice, congestion or popping of the ears, itching of the throat or ears. ●Sleep – Mouth breathing, frequent awakening, daytime fatigue, difficulty performing work.

Differential Diagnosis Acute or Chronic Sinusitis Nasal Polyps Infectious Rhinitis Asthma Atopic dermatitis Allergic Conjunctivitis Food Allergy

Social/ Environmental Considerations Avoid exposure to Cigarette smoke Pets Allergen with known sensitivity Prevention has been a large focus in the study of allergic rhinitis. Allergen avoidance and patient education are key.

Diagnostics Complete history including your health, your symptoms, and whether members in your family have similar symptoms. Physical Exam Skin testing Radioallergosorbent test (RAST) Diagnosis of allergic rhinitis is typically completed with a H&P. lab testing and imaging is not routinely completed. Skin testing is done to identify the allergen for immunotherapy. (testing for immediate hypersensitivity reactions) which indirectly measures the quantity of specific IgE to a particular antigen

Skin Testing

Treatment There are 3 mainstays of treatment of allergic rhinitis Allergen avoidance Medication Allergy Immunotherapy (Rafiq, 2014)

Avoidance Keep windows closed and use air-conditioning in the summer, if possible. Automobile air conditioners help, too. Don't hang clothing outdoors to dry. Pollen may cling to towels and sheets. The outdoor air usually is most heavily saturated with pollen and mold between 5 a.m. and 10 a.m., so early morning is a good time to limit outdoor activities. Wear a pollen mask (such as a NIOSH rated 95 filter mask) when mowing the lawn, raking leaves or gardening, and take appropriate medication beforehand. ("Allergic rhinitis," 2010) Avoid the allergen that causes your symptoms.

Medication Intranasal Corticosteroid: Flonase, Nasacort, Nasonex Antihistamines: 1st Gen- Benadryl 2nd Gen- Clarinex, Claritin, Zyrtec, Allegra Decongestants Phenylephrine, Pseudoephedrine, Oxymetazoline (Afrin) Leukotriene Antagonists Montelukast(generally should be used as an adjunct, not monotherapy) (Rafiq, 2014) They can significantly reduce nasal congestion as well as sneezing, itching and runny nose. These drugs are frequently prescribed, and are of particular value when rhinitis symptoms are more severe. They are most effective when taken daily, as directed by your health care provider, but may have some benefit when taken as needed. These medications counter the effects of histamine, the irritating chemical released within your body when an allergic reaction takes place. Although other chemicals are involved, histamine is primarily responsible for causing the symptoms. Antihistamines do not cure, but help relieve nasal allergy symptoms such as: Sneezing, itchy, and runny nose Eye itching, burning, tearing and redness Itchy skin, hives, and eczema Certain other allergic conditions. 2nd generation antihistamines and intranasal corticosteriod are first line therapies for allergic rhinitis.

Immunotherapy Immunotherapy should be considered for patients with moderate to severe persistent allergic rhinitis that is not responsive to usual treatments. Consists of a small amount of allergen extract given sublingually or subcutaneously over the course of a few years. (Sur & Scandale, 2010) Immunotherapy should be considered for patient with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments. The greatest risk with immunotherapy is anaphylaxis

Complications Secondary infection such as otitis media or sinusitis Epistaxis Nasopharyngeal lymphoid hyperplasia Airway hyperactivity with allergen exposure Asthma Sleep disturbance (Rafiq, 2014)

Follow up/Education/Referral Follow up 2-3 weeks after initial visit then quarterly or biannually No specific restrictions on activity; emphasize avoiding activity where exposure to the allergen is likely No special diet unless food causes a reaction Nasal Saline use has evidence of efficacy as sole agent or as adjunctive treatment Refer to an allergist for consideration of immunotherapy (Rafiq, 2014) Check with patient be sure they are adhering to the education and treatment plan and the effectiveness of the treatments

Question 1 Rhinitis is an inflammation of the nasal mucosa characterized by nasal congestion, rhinorrhea, sneezing, pruritus, and/or postnasal drainage. True or False

Answer 1 1. True: Rhinitis is caused by an inflammation of the nasal mucosa. Many different characteristics appear with rhinitis including nasal congestion, rhinorrhea, sneezing, pruritus, and/or postnasal drainage.

Question 2 2. The mean age for the onset of symptoms of allergic rhinitis is: A. 5-7years of age B. 10-20 years of age C. 40-50 years of age D. 35-40 years of age

Answer 2 2. B. 10-20 years of age: onset of symptoms occur within the first two decades of life, rarely before 6months and with tendency to decline with advance in age.

Question 3 3. Nasal mucosa in a patient with allergic rhinitis will appear? A. Red and swollen B. Pale and boggy C. Red and dry

Answer 3 3. B. Pale and boggy mucosa will suggest allergic rhinitis. Red and swollen can suggest a patient who has a acute allergic rhinitis. While a red and dry mucosa can suggest decongestant use or anticholinergic effect.

Question 4 4. There are two ways to treat allergic rhinitis this is the use of medications and allergy immunotherapy? True or False

Answer 4 4. False. There are three mainstays of treatment of allergic rhinitis Allergen avoidance Medications Allergy immunotherapy

Question 5 5. A patient is in the office for allergic rhinitis, they have dark circles under their eyes, these are known as? A. Periorbital dark circles B. Allergic shiners C. Allergic circles

Answer 5 5. B. Allergic shiners: caused by blood pooling under the eyes as the result of nasal and sinus congestion. You can prevent them through the use of medication, by avoiding common allergens or by having an allergy shot.

Question 6 6. Immunotherapy should be considered for patients with mild to moderate allergic rhinitis? True or False

Answer 6 6. False. Immunotherapy should be considered for patients with moderate to severe persistent allergic rhinitis that is not responsive to usual treatments.

Question 7 7. Allergic rhinitis can be classified into seasonal or perennial and can be intermittent or persistent? True or False

Answer 7 7. True. Allergic rhinitis is classified as either; Seasonal- usually due to outdoor allergens Perennial- year round symptoms, indoor allergens

Question 8 8. Patient education is important with allergic rhinitis, allergen avoidance, is one of three mainstays of treatment? True or False

Answer 8 8. True. Allergen avoidance, medications, and immunotherapy are the three mainstays of treatment. Educating your patient is critical, so the patient has an understanding of limiting their exposure to the offending allergen.

Question 9 9. Second generation antihistamines and intranasal corticosteroid are first line therapies for allergic rhinitis? True or False

Answer 9 9. True, when treating mild to moderate allergic rhinitis 2nd generation nonsedating antihistamines are first therapy. Intranasal corticosteroid are first line therapy for moderate to severe allergic rhinitis.

Question 10 10. A patient can face complications with allergic rhinitis which include; secondary infections such as otitis media or sinusitis, asthma, or epitaxis? True or False

Answer 10 10. True. Patients can face many complications with allergic rhinitis which include: Secondary infection Epistaxis Nasopharyngeal lymphoid hyperplasia Asthma Sleep disturbances

Reference Allergic rhinitis. (2010). Retrieved from http://www.acaai.org/allergist/allergies/Types/rhinitis/Pages/defult.aspx Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: the art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A. Davis Company. Rafiq, N. (2014). Rhinitis, Allergic. In F. Domino (Ed.), The 5-minute clinical consult (22ed., pp. 1078-1079). Philadelphia: Lippincott Williams & Wilkins. Sheikh, J. (2014, April 28). Allergic rhinitis. Retrieved from http://emedicine.medscape.com/article/134825-overview Sur, D., & Scandale, S. (2010). Treatment of allergic rhinitis. American family physician, 52(5), 398-403.