Allergic rhinitis: Clinical sciences

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Introduction0:00–0:37

Allergic rhinitis is a hypersensitivity response of the upper respiratory tract to airborne allergens. When these allergens are inhaled, a process is initiated where immunoglobulin E causes mast cells to activate and release inflammatory mediators like histamine and leukotrienes.
These inflammatory mediators then trigger an allergic response. Based on the frequency and severity of the symptoms, allergic rhinitis is categorized as mild intermittent, severe intermittent, mild persistent, and severe persistent.

Allergic Rhinitis0:37–2:06

When a patient presents with a chief concern suggesting allergic rhinitis, first perform a focused history and physical examination.
Your patient will report symptoms which may include nasal congestion, runny nose, sneezing, and an itchy sensation in the nose.
Patients may also have a history of atopic dermatitis or asthma. The physical exam will typically reveal swollen turbinates, clear nasal discharge, cobblestoning of the posterior pharynx, and postnasal drip.
Your patient might also have conjunctival erythema with watery eyes. At this point, you can diagnose allergic rhinitis!
Now, here’s a clinical pearl! Allergic rhinitis generally presents with bilateral symptoms if you observe unilateral swelling of the nasal turbinates, nasal discharge, or ocular signs and symptoms, consider another underlying cause like a medication side effect.
Some medications, such as beta-blockers and ACE inhibitors can induce nasal symptoms that mimic those of allergic rhinitis!
Next, assess the frequency of your patient’s symptoms. If symptoms are present less than or equal to four days per week OR less than or equal to four weeks out of the year, diagnose intermittent allergic rhinitis!

Mild Intermittent Allergic Rhinitis2:06–3:21

Now that you’ve diagnosed intermittent allergic rhinitis, your next step is to assess symptom severity. If your patient reports that their symptoms do not interfere with their quality of life, like minimal work or school absences, diagnose mild intermittent allergic rhinitis.
Intranasal steroids are the first-line pharmacological treatment for allergic rhinitis; however if they’re unable to tolerate an intranasal steroid, you can consider starting your patient on an oral or intranasal antihistamine.
If these medications are ineffective, you can also consider combination therapy with an intranasal antihistamine and an intranasal steroid for better results.
In addition to medications, remember to counsel your patient to avoid known allergic triggers such as pollen, dust, and mold, as well as animal hair and dander!
Here’s a high-yield fact! If your patient’s allergic rhinitis does not improve significantly with an intranasal steroid, adding an oral antihistamine does not typically improve their symptoms.
A more effective combination is to add an intranasal antihistamine. Alright, now that we’ve covered mild intermittent allergic rhinitis, let’s go back and assess symptom severity.

Severe Intermittent Allergic Rhinitis3:21–5:27

If your patient reports that their symptoms do interfere with their quality of life, like frequent work or school absences, diagnose severe intermittent allergic rhinitis.
Treatment includes the same medications used with mild intermittent allergic rhinitis, but you may need to add an oral decongestant.
Combining oral antihistamines with oral decongestants is more effective than oral antihistamines alone for severe symptoms.
Again, counsel your patient to avoid known allergic triggers. In addition, encourage nasal saline irrigation to flush out mucus and allergens.
If your patient’s symptoms don’t improve as expected, they may need allergen testing, usually with intradermal injection of suspected allergens to observe for a local inflammatory response.
Based on these results, your patient might also need allergen-specific immunotherapy! Here’s a clinical pearl to keep in mind!
Allergic rhinitis symptoms frequently trigger asthma exacerbations, especially in patients with severe intermittent allergic rhinitis!
And here’s another clinical pearl! For patients with severe allergic rhinitis, thoroughly review their medications to ensure they’re not taking a topical decongestant.
While oral decongestants are helpful, topical nasal decongestants, like oxymetazoline, can cause a form of rebound nasal congestion called rhinitis medicamentosa!
This form of chronic rhinitis can occur when topical decongestants are used for more than 72 hours. To treat this condition, discontinue the topical decongestant and start a nasal steroid instead.
And remember, rhinitis medicamentosa can take several months to resolve! Alright, let’s go all the way back and assess your patient’s symptom frequency.

Persistent Allergic Rhinitis5:27–5:43

If your patient reports having symptoms for more than four days per week and symptoms for more than four weeks out of the year, diagnose persistent allergic rhinitis!
Next, assess symptom severity. If your patient reports that their symptoms don’t significantly interfere with their quality of life but are more of a mild nuisance, diagnose mild persistent allergic rhinitis!

Mild Persistent Allergic Rhinitis5:43–7:13

Treatment includes the same medications used with mild intermittent allergic rhinitis; however, montelukast, a leukotriene receptor antagonist, is an option as well, especially for patients who may also have asthma.
Again, counsel your patient to avoid known allergic triggers, and encourage nasal saline irrigation. And remember, your patient may need allergen testing and immunotherapy if symptoms don’t improve.
Here’s another clinical pearl to keep in mind! If your patient needs combination therapy, the most effective approach is a combination nasal spray containing an intranasal antihistamine and an intranasal steroid, such as azelastine with fluticasone.
Alternatively, while not as effective, you can combine montelukast with or without an oral antihistamine. Now, here’s a high-yield fact!
Patients taking certain medications for HIV, such as cobicistat or ritonavir, should not take intranasal steroids. This is because cobicistat and ritonavir can increase the serum concentration of steroid medications, resulting in high risk side effects like Cushing syndrome.
Alright, now that we’ve discussed mild persistent allergic rhinitis, let’s go back and assess your patient’s symptom severity.

Severe Persistent Allergic Rhinitis7:13–7:53

If your patient reports symptoms that significantly interfere with their quality of life, diagnose severe persistent allergic rhinitis.
Treatment includes the same medications used for the other types of allergic rhinitis, but keep in mind your patient will likely require combination therapy for symptom management!
Again, counsel your patient to avoid known allergic triggers, encourage nasal saline irrigation, and recommend allergen testing and immunotherapy if symptoms don’t improve.
Alright, as a quick recap… Allergic rhinitis is a hypersensitivity response of the upper respiratory tract to airborne allergens.

Review7:53–8:32

Symptoms are classified as intermittent or persistent based on the frequency of the symptoms; then further categorized as mild or severe.
Treatment options include intranasal steroids, intranasal antihistamines, oral antihistamines, montelukast, oral decongestants, and allergen avoidance.
If symptoms fail to resolve with medication therapy, consider allergy testing and possible immunotherapy.
Allergic rhinitis: Clinical Sciences: Video | Osmosis