Allergic rhinitis

• Inflammatory disorder where membranes lining nose become sensitised to allergens. Sensitisation (production of IgE specific to that allergen); re-exposure: release of histamine and other inflammatory mediators. Children/adolescents more likely to have seasonal; adults more likely to have perennial

• Seasonal: if caused by grass/tree pollens known as 'hayfever': trees (usually pollinate in spring), grass (pollinate end of spring/beginning of summer), weeds (early spring to late autumn). Perennial: typically due to allergens from house dust mites and pets. House dust mites (peak in spring/autumn. Feed on shed human skin flakes). Animal hair (Common: cats and dogs. Less common: horses/cattle/rabbits/rodents). Occupational: e.g. flour/latex/wood dust

• Symptoms: sneezing; itching, nasal discharge (rhinorrhoea), obstruction, eye symptoms: bilateral itching, redness, swelling

• Differential diagnosis: Infective cause (acute onset, features of URTI, green/yellow discharge); irritant cause: physical (changes in temperature/humidity), chemical (volatile chemicals/odours). Non-allergic causes of rhinitis: autonomic (vasomotor) rhinitis e.g. changes in air temperature, tobacco smoke and perfumes. Drugs (ACE inhibitors, b-blockers, chlorpromazine, aspirin, NSAIDS, cocaine), hormones (pregnancy, OC, hypothyroidism), food and drink (alcohol, spicy foods can cause rhinorrhoea and facial flushing); non-allergic rhinitis with eosinophilia syndrome (NARES); structural/mechanical factors; deviated nasal septum, nasal polyps, hypertrophic turbinates, adenoidal hypertrophy, foreign bodies, nasal tumours (rare); systemic conditions: cystic fibrosis, primary ciliary dyskinesia (Kartagner's syndrome), granulomatous disease (e.g. Wegener's granulomatosis/sarcoid)

• Diagnosis: clinical, FH and exclude other causes. Refer to an immunologist for skin prick testing if type of rhinitis is unclear or symptoms are persistent or poorly controlled. If skin prick testing is not available or the person is using an antihistamine, tricyclic antidepressants (TCAs), or topical corticosteroid (which can suppress results of test) send blood for serum total and specific IgE testing [RAST] OR enzyme-linked immunosorbent assay [ELISA]. If allergy test negative, consider non-allergic cause e.g. due to drugs, hormonal or non-allergic rhinitis with eosinophilia syndrome

Management

• Few indications for nasal sprays and drops except in allergic rhinitis and perennial rhinitis. Nasal preparations containing sympathomimetic drugs may damage the nasal cilia.

• Occasional symptoms: oral antihistamines (cetirizine/loratidine/fexofenadine) reduce rhinorrhoea/sneezing, not so good for nasal congestion or intranasal antihistamines (Azelastine) PRN - useful for controlling breakthrough symptoms

• Preventative treatment for more frequent/persistent symptoms: nasal blockage/congestion/polyps: intranasal corticosteroids; sneezing/nasal discharge: oral antihistamine (if eye symptoms) or intranasal antihistamines (if more effective treatment required). In seasonal allergic rhinitis (e.g. hay fever), treatment should begin 2 to 3 weeks before the season commences and may have to be continued for several months; continuous treatment may be required for years in perennial rhinitis.

• Stepping-up treatment: combine antihistamines / intranasal corticosteroids; intranasal ipratropium (can reduce rhinorrhoea); topical nasal degongestants (nasal blockage). Severe symptoms: Prednisolone 20-40mg OD for 5-10D (10mg OD children) e.g. for short periods, for example, in students taking important examinations. Leukoriene receptor antagonists (e.g. Montelucast) NOT recommended due to lack of evidence (Montelukast is less effective than topical nasal corticosteroids; ??montelucast can be used in patients with seasonal allergic rhinitis and concomitant asthma). Sodium cromoglicate is an alternative, but may be less effective.

• Topical nasal decongestants can be used for a short period to relieve congestion and allow penetration of a topical nasal corticosteroid. Systemic nasal decongestants are of doubtful value

• Pregnancy/breastfeeding: First line: intranasal corticosteroids (e.g. beclometasone dipropionate, budesonide, fluticasone). Alternative treatments: Antihistamines (Loratadine), intranasal sodium cromoglicate, nasal douching (normal saline) or sea water (Sterimar)

Examination/important event

• Chlorphenamine: unacceptable sedation

• IM steroids: no longer recommended due to longevity of action, avascular necrosis and skin atrophy

• OTC non-sedating oral antihistamine and steroid nasal spray is appropriate

Resources

• Allergic Rhinitis (CKS), Rhinitis (Guidelines.co.uk), Allergic rhinitis, A guide to the management of acute rhinosinusitis in primary care managament strategy based on best evidence and recent European guidelines (BJGP)

Corticosteroids

• Avoid in the presence of untreated nasal infections, after nasal surgery (until healing has occurred), and in pulmonary TB. Systemic absorption may follow nasal administration if high doses are used or if treatment is prolonged (drops > sprays). Monitor growth in children

• Fluticasone (Flixonsase / Avamys / Nasofan) (4 years+); Mometasone (Nasonex) (6 years+); Budesonide (Rhincort) (12 years +); Beclometasone BD (Beconase) (6 years +); Betamethasone 2-3 times daily (Betnesol / Vistamethasone)

Nasal polyps

• Short-term use of corticosteroid nasal drops helps to shrink nasal polyps; to be effective, the drops must be administered with the patient in the ‘head down’ position.

• A short course of a systemic corticosteroid may be required initially to shrink large polyps. A corticosteroid nasal spray can be used to maintain the reduction in swelling and also for the initial treatment of small polyps.

Topical nasal decongestants

• Nasal mucosa is sensitive to changes in atmospheric temperature and humidity and these alone may cause slight nasal congestion.

• These symptoms are particularly noticeable in the later stages of the common cold. Sodium chloride 0.9% given as nasal drops or spray may relieve nasal congestion by helping to liquefy mucous secretions.

• Inhalation of warm moist air is useful in the treatment of symptoms of acute infective conditions. The addition of volatile substances such as menthol and eucalyptus may encourage the use of warm moist air

• Symptoms of nasal congestion associated with vasomotor rhinitis and the common cold can be relieved by the short-term use (usually not longer than 7 days) of decongestant nasal drops and sprays. These all contain sympathomimetic drugs which exert their effect by vasoconstriction of the mucosal blood vessels which in turn reduces oedema of the nasal mucosa. They are of limited value because they can give rise to a rebound congestion (rhinitis medicamentosa) on withdrawal, due to a secondary vasodilatation with a subsequent temporary increase in nasal congestion. This in turn tempts the further use of the decongestant, leading to a vicious cycle of events. Ephedrine hydrochloride nasal drops is the safest sympathomimetic preparation and can give relief for several hours. The more potent sympathomimetic drugs oxymetazoline and xylometazoline hydrochloride are more likely to cause a rebound effect.

Nasal preparations for infection

• ​There is no evidence that topical anti-infective nasal preparations have any therapeutic value in rhinitis or sinusitis

Nasal staphylococci

• Elimination of organisms such as staphylococci from the nasal vestibule can be achieved by the use of a cream containing chlorhexidine and neomycin (Naseptin), but re-colonisation frequently occurs. Coagulase-positive staphylococci are present in the noses of 40% of the population.

• Nasal ointment containing mupirocin should probably be held in reserve for resistant infections / eradication of nasal carriage of MRSA. A sample should be taken 2 days after treatment to confirm eradication. The course may be repeated if the sample is positive (and the throat is not colonised). To avoid the development of resistance, the treatment course should not exceed 7 days and the course should not be repeated on more than one occasion. If the MRSA strain is mupirocin-resistant or does not respond after 2 courses, consider alternative products such as chlorhexidine and neomycin cream.

Resources

• Nose treatment summary (BNF), Steroid nasal sprays (patient.info), Allergic rhinitis (CKS)