Allergy: Definitions, Symptoms, and Treatment - PDF

Allergy CMS250 Week 6 Learning Outcomes Analyze the definition, symptoms, and prevalence of allergic rhinitis (AR), including its impact on school and work performance, and the different populations affected. Implement diagnostic essentials of AR including the associated symptoms, physica...

Allergy CMS250 Week 6 Learning Outcomes Analyze the definition, symptoms, and prevalence of allergic rhinitis (AR), including its impact on school and work performance, and the different populations affected. Implement diagnostic essentials of AR including the associated symptoms, physical examination findings, and the role of allergy testing. Distinguish AR from other types of nonallergic rhinitis such as vasomotor rhinitis, rhinitis medicamentosa, and viral upper respiratory infections Categorize the common causes and triggers of AR, differentiating between seasonal (intermittent), perennial (chronic), and occupational rhinitis. Evaluate the potential impact of climate change on the occurrence of AR. Learning Outcomes Investigate the classification of AR based on severity and duration, and the proposed classification systems. Identify the associated conditions of AR such as asthma, atopic dermatitis, and conditions that can mimic AR. Critique the link between AR and asthma. Enumerate complications associated with AR such as chronic rhinosinusitis, nasal polyposis, and the potential side effects and contraindications of allergy skin testing. Appraise the importance of taking a thorough patient history in the evaluation of AR and the role of family history in atopy or allergy. Learning Outcomes Study the different expert panels and their reports on rhinitis, and assess the role of an interprofessional team in improving care for patients with AR. Formulate a thorough patient assessment for AR, develop an assessment plan, and determine when referral to an otolaryngologist or allergist may be appropriate. Assess nonallergic rhinitis and its causes and learn about nonallergic rhinitis with eosinophilia syndrome. Analyze the controversy surrounding nonallergic rhinitis and its diagnosis. Evaluate the different diagnostic tests available for AR and the challenges and recommendations for allergy testing in children. Allergic Rhinitis Allergy: Definitions Allergy: the clinical manifestation of an adverse immune response after repeated contact with a typically harmless substance (e.g., pollens, mold spores, animal dander, dust mites, foods, stinging insects), regardless of mechanism (Shah and Emanuel, 2020) Atopy: the predisposition to an immune response against antigens and allergens, leading to CD4+ Th2 differentiation and overproduction of IgE (Type 1 hypersensitivity reaction) Allergy: Definitions Allergic rhinitis: an inflammation of the nasal mucous membranes caused by an IgE-mediated response to exposure to one or more allergens One of the more common manifestations of atopy, along with asthma and eczema Allergy: Epidemiology Historically, allergic rhinitis was thought to be a disease process of the nasal airway alone Now allergic rhinitis has been classified as a component of systemic allergic response (e.g., asthma, atopic dermatitis) – with an underlying systemic pathology (Akhouri, 2023) Allergy: Epidemiology Very common: 20-30% of adults and up to 40% of children in the U.S. (Kozin and Lustig, 2023) Approximately 40 million people in the U.S. (Shah and Emanuel, 2020) More than 500 million people worldwide (Kendrick, 2022) Allergy: Epidemiology The Agency for Healthcare Research and Quality (AHRQ) reported that allergic rhinitis is the sixth most prevalent chronic illness (Wheeler and Wheeler, 2005) Treatment costs are at least $1.8 billion annually for physician visits and medications Allergy: Epidemiology According to the European Community Respiratory Health Survey (ECRHS) – among adult populations: In 1995, a prevalence of self-reported nasal allergies of 20.9% (9.5% to 40.9%) Commonly proposed in the literature that rhinitis prevalence has increased in recent decades, across almost all geographical regions, but the literature review is lacking on this topic Allergy: Epidemiology One of the most common chronic pediatric disorders From the International Study for Asthma and Allergies in Childhood (ISAAC) 2004 and based on data from 97 countries (Savouré et al., 2022): 14.6% in the 13-14 year age group and 8.5% in the 6-7 year age group display symptoms of rhinoconjunctivitis linked to allergic rhinitis (Akhouri, 2023) Self-reported current nasal symptoms of 31.7% (11.9% to 80.6%) Prevalence of allergic rhinitis by age group. Citation: Chapter 14 Nonallergic and Allergic Rhinitis, Lalwani AK. Current Diagnosis & Treatment Otolaryngology—Head and Neck Surgery, 4e; 2020. Available at: https://accessmedicine.mhmedical.com/content.aspx?sectionid=229671736&bookid=2744&Resultclick=2 Accessed: December 03, 2023 Copyright © 2023 McGraw-Hill Education. All rights reserved Allergy: Epidemiology Onset at any age, but incidence of onset is greatest in adolescence – with decreasing incidence with advancing age 80% of people diagnosed before age 20 (Kendrick, 2022) Peak prevalence during third and fourth decades of life Allergy: Epidemiology In a longitudinal study, at the 23-year follow-up visit: 54.9% of patients showed improvement in symptoms, with 41.6% of those being symptom-free Patients who had an onset of symptoms at a younger age were more likely to show improvement Allergy: Risk Factors Associated with genetic predisposition – children have a 30% chance of developing allergic rhinitis if one parent is affected, and a 50% chance of both parents are affected (Kendrick, 2022) Severity of allergic rhinitis can vary over time and depends on various factors, such as location and season Allergy: Risk Factors Risk factors for developing allergic rhinitis include: family history of atopy, male sex, a presence of allergen-specific IgE, a serum IgE greater than 100IU/mL before age 6, and higher socioeconomic status Studies in young children have shown a higher risk of allergic rhinitis in those with an early introduction to foods or formula and/or heavy exposure to cigarette smoking in the first year of life (Akhouri, 2023) Allergy: Protective Factors? Several possibly protective factors have been identified – breastfeeding, early pet exposure, and the “farm effect” Meta-analysis of 8 studies showed a 40% lower risk in subjects who had lived on a farm during their first year of life (Akhouri, 2023) Impact of Allergic Rhinitis Adversely affects school and work performance – sleep deprivation, fatigue and reduced productivity, absenteeism Economic costs (direct and indirect) are considerable – from the allergy symptoms, prescription and non-prescription medications, negative side effects of allergy medication Impact of Allergic Rhinitis Although non-life-threatening, the symptomatic effects are considerable and result in a significantly diminished quality of life for many (social and physical functionality, energy and fatigue levels, lack of sleep and mental health) May contribute to sleep disorders, fatigue, and learning problems Diagnosis of Allergic Rhinitis Allergic Rhinitis: Diagnostic Approach Patient history Symptoms Physical examination findings Allergy testing Patient History – Intake A thorough and comprehensive history is an essential part of the evaluation of allergic rhinitis Questions should focus on: symptoms (onset, duration, exposures, magnitude of reaction, patterns, chronicity); exacerbating/alleviating factors; seasonal variation; environmental influences; allergies; medical history; and past and current treatments Patient’s age at onset of symptoms can be helpful to know Patient History – Intake Constitutional symptoms (headache, malaise, fatigue) are also common Personal history of asthma Persistent symptoms may be due to exposure to an indoor allergen Seasonal symptoms or symptoms that are reproducible from a triggering factor are most likely to be allergic E.g., environmental allergen exposure in the presence of allergen-specific IgE Patient History – Intake Acute onset (one week or less) usually suggests a viral etiology, acute exacerbation of allergic rhinitis, or possibly a foreign body (more commonly unilateral and in children) Chronic symptoms with seasonal variations suggest seasonal allergic rhinitis Chronic acute rhinitis often has postnasal drip, chronic nasal congestion, and obstruction Patient History – Intake If use of antihistamines or intranasal corticosteroids improves symptoms, then allergy is probable However, intranasal or oral decongestants will affect both allergic and nonallergic symptoms History of anaphylactic reaction following ingestion of a particular food or being stung by an insect usually indicates an atopic patient Patient History – Intake Use of certain medications can lead to symptom of rhinitis Beta-blockers, acetylsalicylic acid, NSAIDs, ACE inhibitors, and hormone therapy Patient History – Environment Evaluation of the patient’s home and work/school environments to determine potential triggers Common allergens: pollens, furred animals, textile flooring/upholstery, tobacco smoke, humidity levels at home, other noxious substance exposure Patient History – Environment Seasonal allergic rhinitis is most commonly caused by pollens and spores Flowering shrub and tree pollens in the spring; flowering plants and grasses in the summer; and ragweed and molds in the fall Dust, household mites, air pollution, and pet dander may produce year-round “perennial rhinitis” Patient History – Family History Allergy or atopy tend to be hereditary Genetic factors determine the likelihood of becoming sensitized and producing IgE antibodies Family history of allergies, eczema, or asthma increases this possibility Children with parents who have allergies have been shown to have a >50% chance of becoming allergic themselves Patient History – Family History In infancy and childhood, food allergens (e.g., milk, eggs, soy, wheat), dust mites, and inhalant allergens (e.g., pet dander) are the major causes of allergic rhinitis and the comorbidities of atopic dermatitis, otitis media with effusion, and asthma In older children and adolescents, pollen allergens are more of a causative factor Table 3-3 Clinical Manifestations of Allergic Rhinitis Sneezing paroxysms Transverse nasal crease Nasal, ocular, palatal itching Infraorbital cyanosis (“allergic shiners”) Clear rhinorrhea Serous otitis media Nasal congestion Laboratory findings Nasal eosinophilia Evidence of allergen-specific IgE by skin or RAST Pain, bluish nasal mucosa Kishiyama, J.L., Chang, J.J., & Donovan, S.M. Disorders of the Immune System. In: Hammer GD, McPhee SJ. eds. Pathophysiology of Disease: An Introduction to Clinical Medicine, 8e. McGraw Hill; 2019. Accessed December 03, 2023. https://accessmedicine-mhmedical-com.ccnm.idm.oclc.org/content.aspx?bookid=2468&sectionid=198219961. Symptomology Nasal congestion, clear rhinorrhea, sneezing, postnasal drip, and nasal pruritis Allergic conjunctivitis: eye irritation and excessive tearing (more commonly associated with animal and outdoor allergens) Associated Symptoms Chronic sinusitis, nasal polyposis Non-productive cough, bronchospasm, eczematous dermatitis Snoring, sleep apnea, sleep disturbance Headache, difficulty concentrating, low mood, fatigue Associated Symptoms in Children Malaise or fatigue may be presenting complaints in children Sinusitis, Eustachian tube dysfunction and otitis media with effusion Asthma Snoring Possible dental overbite and high-arched palate due to chronic mouth breathing Physical Examination Visualization of patient’s appearance Nose Ears Sinuses Posterior oropharynx Additional: Lymph Nodes, Chest and Skin Physical Exam – Visualization Eyes: conjunctivitis Allergic shiners: blue-grey or purple discolouration under the lower eyelids Mouth breathing Frequent sniffling and/or throat clearing Physical Exam – Nose “Nasal salute”: transverse nasal crease due to constant rubbing of the nose in an upwards motion Hyperpigmented horizontal nasal crease in a patient with the atopic triad who repeatedly performs the allergic salute when her nose is feeling itchy. (Reproduced with permission from Richard P. Usatine, MD.) Citation: Chapter 151 Atopic Dermatitis, Usatine RP, Smith MA, Mayeaux, Jr. EJ, Chumley HS. The Color Atlas and Synopsis of Family Medicine, 3e; 2019. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=2547&sectionid=206794809 Accessed: December 03, 2023 Copyright © 2023 McGraw-Hill Education. All rights reserved Transverse nasal crease (A) 2 transverse lines crossing the bridge of nose (arrows). (B) Individual upwardly rubbing nose, referred to as 'allergic salute'. DynaMed. Allergic Rhinitis. EBSCO Information Services. Accessed December 4, 2023. https://www-dynamed-com.ccnm.idm.oclc.org/condition/allergic-rhinitis Physical Exam – Nose Endoscopic nasal exam to assess for structural abnormalities (e.g., septal deviation, nasal ulcerations, and nasal polyps) “Cobblestoning” of nasal mucosa, mucosal swelling, and discharge Boggy, pale, or “bluish” (violaceous) nasal turbinates due to venous engorgement Consider assessment before and after decongesting with a topical decongestant for comparison Nasal Polyposis Incidence in the general population is 4%; more common in males The result of chronic inflammation of the paranasal sinus mucosa Usually bilateral Unilateral nasal polyps should raise concerns for malignancy Typically benign Nasal polyp in right nasal cavity in a patient with inflamed mucosa from allergic rhinitis. (Reproduced with permission from William Clark, MD.) Citation: Chapter 32 Nasal Polyps, Usatine RP, Smith MA, Mayeaux, Jr. EJ, Chumley HS. The Color Atlas and Synopsis of Family Medicine, 3e; 2019. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=2547&sectionid=206778268 Accessed: December 03, 2023 Copyright © 2023 McGraw-Hill Education. All rights reserved Nasal polyp in left middle meatus with normal surrounding mucosa. (Reproduced with permission from William Clark, MD.) Citation: Chapter 32 Nasal Polyps, Usatine RP, Smith MA, Mayeaux, Jr. EJ, Chumley HS. The Color Atlas and Synopsis of Family Medicine, 3e; 2019. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=2547&sectionid=206778268 Accessed: January 14, 2024 Copyright © 2024 McGraw-Hill Education. All rights reserved Physical Exam – Ears Generally appear normal; however, assessment for Eustachian tube dysfunction using a pneumatic otoscope should be considered Physical Exam – Sinuses Palpation of sinuses May elicit tenderness in patients with chronic symptoms Tapping of maxillary teeth with a tongue depressor for evidence of sensitivity Physical Exam – Posterior Oropharynx Postnasal drip: mucous accumulation in the back of the nose and throat Enlarged tonsils: inversely associated with allergic rhinitis Physical Exam – Additional Exams Lymphadenopathy: to rule out viral or bacterial cause of the rhinitis Chest: signs of concurrent asthma (e.g., wheezing) Skin: signs of concurrent dermatitis Physical Exam – Pediatric In children, allergic “shiners”, facial grimacing, mouth breathing, and the “nasal salute” are common physical findings Concomitant otitis media with effusion is also possible Vernal Conjunctivitis. The tarsal conjunctiva demonstrates giant papillae and a cobblestone appearance pathognomonic for vernal conjunctivitis. (Photo contributor: William Beck, CRA.) Citation: 2-07 Allergic Conjunctivitis, Knoop KJ, Stack LB, Storrow AB, Thurman R. The Atlas of Emergency Medicine, 5e; 2021. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250454182 Accessed: January 14, 2024 Copyright © 2024 McGraw-Hill Education. All rights reserved Diagnostic Testing Allergy Testing Allergy Testing General recommendations for allergy testing vary No specific recommendation on when to perform allergy testing for patients with rhinitis In vitro testing process. Citation: Chapter 14 Nonallergic and Allergic Rhinitis, Lalwani AK. Current Diagnosis & Treatment Otolaryngology—Head and Neck Surgery, 4e; 2020. Available at: https://accessmedicine.mhmedical.com/content.aspx?sectionid=229671736&bookid=2744&Resultclick=2 Accessed: December 03, 2023 Copyright © 2023 McGraw-Hill Education. All rights reserved Allergy Testing Based on a systematic review on allergy testing (Quillen and Feller, 2006): Tests should be selected that will change outcomes or treatment plans Empiric treatment is appropriate in patients with classic symptoms Diagnostic tests may be appropriate if severe symptoms or an unclear diagnosis is present Allergy Testing Based on a systematic review on allergy testing (Quillen and Feller, 2006): The patient is a potential candidate for allergen avoidance treatment or immunotherapy Observation may be appropriate for patients with mild symptoms or an unclear history Allergy Testing Skin Testing Skin Prick Intradermal Serum Testing (IgE) Skin Testing Considered the primary method for identifying specific allergic triggers of rhinitis Quick in-office procedure and results are available immediately Specific and slightly higher sensitivity (verses serum testing) More cost effective (verses serum testing) Skin Testing Safe Allows for uniformity in the testing procedure Requires a trained technician Skin Testing H2-receptor antagonists, tricyclic antidepressants, and anti-IgE monoclonal antibody omalizumab can interfere with allergy skin test response Recommended to stop medication before testing Contraindications: patients with uncontrolled or severe asthma, unstable cardiovascular disease, pregnancy, concurrent beta- blocker therapy Skin Testing Primary goal is to detect the immediate allergic response caused by the release of mast cell or basophil IgE-specific mediators, which create the classic wheal-and-flare reaction Testing is typically performed using the allergens relevant to the patient’s environment Percutaneous (prick or puncture) and intradermal methods Skin Prick Testing Involves placing a drop of a commercial extract of a specific allergen on the skin of the forearms or back Then, pricking the skin through the drop to introduce the extract into the epidermis Within 15-20 minutes, a wheal-and-flare response will occur if the test is positive Skin prick allergy test With skin prick testing, a lancet or needle scratches the surface of the skin, allowing a tiny amount of the potential allergen to be deposited in the epidermis. It is often performed with a multi-head testing device for ease and patient comfort. DynaMed. Allergic Rhinitis. EBSCO Information Services. Accessed December 4, 2023. https://www-dynamed-com.ccnm.idm.oclc.org/condition/allergic-rhinitis Intradermal Testing More sensitive than the skin prick test and provides more consistent results Involves injection of a small amount (max 0.05mL) of the suspected allergen under the surface of the skin, in order to raise a bleb 4-6mm in diameter Examine the area for a reaction after 15-20 minutes A typical reaction looks like a small hive with swelling and redness Intradermal Testing An increase in wheal size of 3mm in diameter beyond the initial bleb is considered positive A bleb that has not increased but has persisted, is itchy and has an associated flare does not meet the criteria for a positive result Intradermal skin test Intradermal skin testing for anesthetics and other drugs. DynaMed. Allergic Rhinitis. EBSCO Information Services. Accessed December 4, 2023. https://www-dynamed-com.ccnm.idm.oclc.org/condition/allergic-rhinitis Serum Testing Allergen-specific serum IgE testing (e.g., performed by immunosorbent assay) Provides an in-vitro measure of a patient’s specific IgE levels against particular allergens Easy and accurate for atopic allergy Serum Testing With newer in-vitro technology, serum testing is now equivalent to skin testing in efficacy Though the original in-vitro assay the radioallergosorbent (RAST) test is no longer performed, the name is still used to generally describe IgE-specific blood testing Serum Testing Safe, specific, cost-effective, reproducible Does not require trained technicians Patient is not required to stop taking antihistamines in advance Easy and quick, therefore preferred especially in children and anxious patients Allergy Testing in Children A large literature review provided evidence-based recommendations for allergy testing in children with various allergic diseases (e.g., rhinitis, asthma, food allergy) Conclusion: percutaneous skin testing is appropriate for children 3 years and older, and RAST testing is appropriate at any age Recommendation: base testing decisions on clinical history and perform tests only when needed to change therapy or clarify a diagnosis Nasal Cytology Not needed for routine diagnosis, but consider if the diagnosis is unclear Sample should be taken from the middle part of the inferior turbinate of both nostrils, and immediately smeared on a glass slide After air-drying, samples are stained and viewed under a microscope Nasal Cytology The presence of inflammatory cells (eosinophils, mast cells, neutrophils, and plasma cells) infiltrating the nasal mucosa and releasing chemical mediators, is thought to be responsible for the main symptoms of allergic rhinitis (e.g., itching, nasal congestion, runny nose, sneezing) Differentials List Table 28-1 Differential Diagnosis for Congestion and Rhinorrhea Common cold Seasonal allergic rhinitis Sinusitis Vasomotor rhinitis Viral Rhinitis secondary to ⍺-agonist withdrawal Allergic Drug-induced rhinitis (e.g., cocaine) Bacterial Nasal foreign body Fungal Dabelić, A. Respiratory Problems. In: South-Paul JE, Matheny SC, Lewis EL. eds. CURRENT Diagnosis & Treatment: Family Medicine, 5e. McGraw Hill; 2020. Accessed December 03, 2023. https://accessmedicine- mhmedical-com.ccnm.idm.oclc.org/content.aspx?bookid=2934&sectionid=247400317. Table 14-1 Types of Rhinitis Allergic Infectious Nonallergic, Noninfectious Rhinitis Miscellaneous Rhinitis Rhinitis Seasonal Viral Eosinophilic syndromes Granulomatous NARES rhinitis Nasal polyposis Perennial Bacterial Noneosinophilic syndromes Atrophic rhinitis rhinosinusitis Vasomotor rhinitis Rhinitis medicamentosa Occupational rhinitis Rhinitis of pregnancy Hypothyroidism Medication (e.g., birth control pills) Gustatory rhinitis Shah, S.B. & Emanuel, I.A. Nonallergic and Allergic Rhinitis. In: Lalwani AK. eds. Current Diagnosis & Treatment Otolaryngology—Head and Neck Surgery, 4e. McGraw Hill; 2020. Accessed November 05, 2023. https://accessmedicine- mhmedical-com.ccnm.idm.oclc.org/content.aspx?bookid=2744&sectionid=229671736. Differential Diagnoses Nonallergic rhinitis Viral upper respiratory infections Vasomotor rhinitis Rhinitis medicamentosa Hormonal and drug-induced rhinitis Nonallergic rhinitis with eosinophilia syndrome Nonallergic Rhinitis Diagnosis is made after eliminating allergic or IgE-mediated causes Most common cause is an acute viral infection Less common subtypes: vasomotor rhinitis, drug-induced rhinitis, rhinitis medicamentosa, hormonal rhinitis, non-allergic rhinitis with eosinophilia syndrome Nonallergic Rhinitis Represents at least 23% of rhinitis cases in the U.S. (20-30 million patients); however, pathophysiology is unclear Best current evidence supports nociceptor and autonomic nerve dysregulation as components in all forms of nonallergic rhinitis A negative result on allergy testing is one unifying characteristic of all subtypes Nonallergic Rhinitis More common in women Female-to-male ratio of 2:1 to 3:1 Usually older than 35 years and no family history of allergies Acute Viral Rhinitis (Rhinosinusitis) The leading cause of acute rhinitis Viral causes include rhinoviruses, respiratory syncytial virus, parainfluenza, influenza, adenoviruses Very common; associated with other manifestations of viral illness (e.g., headache, malaise, body aches, cough) Nasal drainage is most often clear or white, and can be accompanied by nasal congestion and sneezing Usual self-limited and requires only symptomatic treatment Acute Viral Rhinitis (Rhinosinusitis) Occasionally, development of a bacterial superinfection or rhinosinusitis can occur Causes include Streptococcus pneumoniae, group A beta- hemolytic streptococci, Haemophilus influenzae Symptoms generally worsen (e.g., facial pain, nasal obstruction, fever) Sinusitis is best diagnosed through history, physical examination, and prediction rules Vasomotor Rhinitis “Vasomotor” implies an increased blood supply to the nasal mucosa, although this has not been proven Suggested that caused by abnormal autonomic regulation of nasal function Possible compounding factors include previous nasal trauma and extraesophageal manifestations of GERD Symptoms mainly consist of congestion, clear nasal drainage, and (less commonly) pruritus and sneezing Vasomotor Rhinitis Unrelated to a specific allergen, infection, or causation Includes patients with perennial symptoms that are associated with temperature changes, humidity, odours, alcohol ingestion, and eating (“gustatory rhinitis”) A diagnosis of exclusion: patients should have normal serum IgE levels, negative skin testing or RAST, and no inflammation on nasal cytology Drug-induced Rhinitis Use of various medications and illicit drugs E.g., antihypertensives, NSAIDs, phosphodiesterase-5 inhibitors, cocaine Rhinitis medicamentosa is an example of this subtype Rhinitis Medicamentosa Often present with nasal obstruction that has worsened over years Typically have been using over-the-counter topical vasoconstrictive nasal sprays, with a need to increase doses of the sprays as tachyphylaxis occurs The use of these sprays for prolonged periods leads to rebound rhinitis with severe obstruction as the effects subside Hormonal Rhinitis Associated with pregnancy The systemic concentration of estrogen rises throughout pregnancy, leading to an increase in hyaluronic acid in the nasal tissue, with subsequent increase in nasal edema and congestion Additionally, there is an increase in mucous glands and decrease in nasal cilia during pregnancy – this heightens nasal congestion and decreases mucous clearance Rhinitis is usually most severe during the second and third trimesters Rhinitis with Nasal Eosinophilia Syndrome Nonallergic rhinitis with eosinophilia (NARES) Inflammatory type of rhinitis with increased eosinophils in secretions and increased mast cells with degranulation (on nasal biopsy) Patients present with nasal obstruction and congestion – therefore, experience more severe exacerbations, including the development of sinusitis and polyposis Also display marked eosinophilia on nasal smears (>25%) but are not allergic to any inhalant allergens by skin testing or in vitro testing Rhinitis with Nasal Eosinophilia Syndrome Testing secretions for eosinophils is not typically performed because their presence/absence does not help distinguish allergic from nonallergic etiologies or change treatment management Cause of NARES remains unknown Nonallergic Rhinitis There is controversy regarding nonallergic rhinitis because the epidemiology and diagnostic criteria are confusing – mainly, how to differentiate allergic rhinitis from nonallergic rhinitis Current research supports a third category that includes characteristics of both allergic and nonallergic rhinitis Prevalence in adults: 43% with pure allergic rhinitis, 34% with combination rhinitis, 23% with pure nonallergic rhinitis (Quillen and Feller, 2006) Nonallergic Rhinitis Management of allergic and nonallergic rhinitis is slightly different; therefore, determining the difference will be important A patient-administered screening tool (Patient Rhinitis Screen) to help identify patients with combination rhinitis is available, but the research is lacking on its use beyond gathering demographic data Subgroups of Allergic Rhinitis Subgroups of Allergic Rhinitis Seasonal Perennial Occupational Seasonal Rhinitis Approximately 20% of cases (Akhouri, 2023) Occur or are increased during certain seasons Usually depending on the pollination of plants to which the patient is allergic Trees = spring; grasses = late spring and summer; weeds (and molds) = fall Seems to be more common in the pediatric age group Seasonal Rhinitis Symptoms include: sneezing; watery rhinorrhea; itching of the nose, eyes, ears, and throat; red and watering eyes; and nasal congestion Usually worse in the morning and aggravated by dry, windy conditions Perennial Rhinitis Approximately 40% of cases (Akhouri, 2023) Symptoms are usually constant, with little seasonal variation, though may vary in intensity Seems to be more prevalent in adults Perennial Rhinitis Symptoms include: nasal congestion and blockage; and postnasal drip Rhinorrhea and sneezing are less common Eye symptoms are less common, except with animal allergies Seasonal pollen may exacerbate any of these symptoms Perennial Rhinitis Common allergens: indoor inhalants – predominantly dust mites, animal dander, mold spores, and cockroaches Certain occupational allergens may cause perennial allergic rhinitis, though these are not usually constant because they depend on workplace exposure Food allergens may also be a trigger – these are often associated with other symptoms (e.g., GI issues, urticaria, angioedema, anaphylaxis) Perennial Rhinitis Infections and nonspecific irritants may influence perennial allergic rhinitis In children with allergies, there may be a higher incidence of respiratory tract infections, which can aggravate allergic rhinitis and lead to complications (rhinosinusitis, otitis media with effusion) Other irritants: tobacco smoke, chemical fumes, air pollutants Systemic Symptoms Both seasonal and perennial allergic rhinitis can be associated with systemic symptoms, such as malaise, weakness, and fatigue Patients may also have allergic conjunctivitis, asthma, and eczema Systemic Symptoms Not all patients fit into the seasonal and perennial classification Some allergic triggers (e.g., pollen) may be seasonal in cooler climates but perennial in warmer climates Patients with multiple “seasonal” allergies may have symptoms throughout most of the year Classification by symptom duration (intermittent or persistent) and severity (mild, moderate, or severe) is preferred Occupational Rhinitis Due to occupational exposure to irritants and allergens Allergen-related = allergic rhinitis category (e.g., laboratory animals, latex, grains, coffee beans, wood dust) Irritant-related = more accurately nonallergic rhinitis (e.g., tobacco smoke, cold air, formaldehyde, hair spray) Symptoms typically worsen throughout the work week and improve with time off Occupational Rhinitis Symptoms include: nasal dryness, congestion, rhinorrhea, and sneezing Decreased ciliary movements within the nose have been seen in chronic cigarette smoke exposure and wood particles exposure Occupational Rhinitis Key to treatment is determining and avoiding the trigger Environmental control by limiting exposure through removal of the causal agent, avoidance, improving ventilation, and the use of protective particulate respirator masks The Effect of Climate Change Climate change may have an impact on the occurrence of allergic rhinitis (Kozin and Lustig, 2023) Increased temperature and carbon dioxide exposure cause increased pollen production, with significantly stronger allergenicity, in ragweed plants Extended summer correlates with longer periods of pollen production in flowering weeds The Effect of Climate Change Levels of some specific aeroallergens are on the rise in particular regions, and may be linked to anthropogenic climate change Due to the warmer temperatures, pollen seasons will start earlier and end later. In North America, the ragweed pollen season has increased by 27 days, from 1995 to 2009 (Sierra- Heredia et al., 2018) The Effect of Climate Change Changes in dispersion, both region- and species-specific, can potentially expose and sensitize populations to novel allergens These changes in dispersion will also impact plant distribution – species that could not survive in previously hostile environments can potentially thrive because of the changes in temperature and precipitation Classification of Allergic Rhinitis Allergic Rhinitis – Classification Duration Severity Classification by Duration Intermittent: < 4 days/week or < 4 weeks’ duration Persistent: ≥ 4 days/week or ≥ 4 weeks’ duration Classification by Severity Mild: symptoms are present but not troublesome; no impairment in daily activities, school or work; and no sleep disturbance. Minimal changes in quality of life. Moderate-to-severe: one or more is present of troublesome symptoms; impairment in daily activities, school or work; or sleep disturbance. Significant changes in quality of life. Algorithm for the diagnosis and management of rhinitis. Persistent is defined as >4 days per week for >4 weeks. Moderate/severe is defined as abnormal sleep, impaired daily activities (school, work, sport, leisure), and/or troublesome symptoms. CysLT, cysteinyl leukotriene; ENT, ear, nose, and throat; IgE, immunoglobulin E. Citation: Chapter 352 Urticaria, Angioedema, and Allergic Rhinitis, Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. Harrison's Principles of Internal Medicine, 21e; 2022. Available at: https://accessmedicine.mhmedical.com/content.aspx?sectionid=264533761&bookid=3095&Resultclick=2 Accessed: December 03, 2023 Copyright © 2023 McGraw-Hill Education. All rights reserved Associated Conditions Atopic Dermatitis, Food Allergies, Asthma Atopy Atopy is the genetic predisposition to developing allergic conditions, such as atopic dermatitis, asthma, allergic rhinitis, food allergies Associated with the presence of allergen-specific IgE Mast cells likely play a role in atopy since they are key effector cells in allergic rhinitis and asthma Atopy may develop into hypersensitivity reactions, particularly urticaria and anaphylaxis Atopic Triad Atopic Triad: atopic dermatitis + allergic rhinitis + asthma Immediate and late cellular phase of allergic inflammation in the skin, nose, or lung with allergen exposure in sensitive individuals The progression from atopic dermatitis to allergic rhinitis to asthma during childhood is referred to as the “Atopic March” “Atopic March” Step 1: Birth to 1 year: Skin irritation (hives, eczema) Step 2: 1-3 years: Food allergies Top 8 are peanut, tree, nut, cow’s milk, egg, wheat, soy, fish, and shellfish Step 3: 4-6 years: Seasonal and environmental allergies, including allergic rhinitis Step 4: 5-7 years: Asthma Asthma 80% of Canadians with asthma also suffer from allergic rhinitis or sinusitis Estimated 30% of children with atopic dermatitis develop asthma later in life (Berke et al., 2012) Allergic rhinitis and sinusitis are associated with more severe or frequent asthma symptoms The two conditions frequently overlap – several of the same allergens are known to trigger asthma and seasonal allergy exacerbations Asthma Seasonal allergies tend to make asthma worse and may be a risk factor for the development of asthma Allergies play a role in asthma, asthma control, and management Effective treatment of seasonal allergies can reduce asthma symptoms and may even help prevent the development of asthma Asthma Other considerations: In asthma, there is an intrinsic hyperreactivity of the airways independent of the associated inflammation Coexistence of asthma, rhinitis, and eczema has been studied in children, but data are lacking in adults (Pullerits et al., 2021) Management of Allergic Rhinitis An Interprofessional Team Approach Management of Allergic Rhinitis Most commonly diagnosed and managed by primary care physicians or providers Patients who do not respond to standard therapies for allergic rhinitis can be referred to a specialist (e.g., allergist or otolaryngologist/ENT) with an allergy focus Management of Allergic Rhinitis Specific findings on the physical exam should also prompt a referral – for example: Multiple nasal polyps in a pediatric patient is suggestive of cystic fibrosis Bloody or unilateral nasal discharge should be referred to an ENT to rule out malignancy Any concerns of cerebrospinal fluid leak causing rhinorrhea Management of Allergic Rhinitis An interprofessional team approach will result in the best outcome Primary care physician Nurse practitioner Allergist ENT specialist Summary Allergic rhinitis is one of the most common chronic conditions affecting the adult and pediatric populations, and with significant costs to health care, school/work performance, and quality of life Allergic rhinitis is one component of a systemic allergic pathology The patient history intake is essential to the evaluation and diagnosis of allergic rhinitis. Physical exams can help to monitor for associated symptoms and sequelae of allergic rhinitis, and rule out other diagnoses. Recommendations on allergy testing will vary. Tests should be selected based on impact on treatment outcomes or plans. Allergic rhinitis may be associated with other atopic conditions, such as atopic dermatitis and asthma Management with an interprofessional approach will provide best patient outcomes References Akhouri, S. (2023). Allergic Rhinitis Article (statpearls.com). Accessed Nov 5, 2023. https://www.statpearls.com/articlelibrary/viewarticle/17370/. Allergy & Asthma Network. (2023). What is the Allergic March? Accessed December 7, 2023. https://allergyasthmanetwork.org/health-a-z/allergic- march/#:~:text=The%20progression%20from%20eczema%20to,33%20perc ent%20develop%20food%20allergies. Ameli, F. et al. Tonsil volume and allergic rhinitis in children. Allergy Rhinol (Providence). 2014 Jan;5(3):137-42. doi: 10.2500/ar.2014.5.0095. PMID: 25565049; PMCID: PMC4275459. Asthma Canada. (2023). Allergies and Asthma. Accessed: November 10, 2023. https://asthma.ca/get-help/allergies-and-asthma/. References Bantz SK, Zhu Z, Zheng T. The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma. J Clin Cell Immunol. 2014 Apr;5(2):202. doi: 10.4172/2155- 9899.1000202. PMID: 25419479; PMCID: PMC4240310. Berke, R., Singh, A., & Guralnick, M. Atopic dermatitis: an overview. Am Fam Physician. 2012;86(1):35-42. PMID: 22962911. Caruso, C. et al. (2022). Nasal Cytology: A Easy Diagnostic Tool in Precision Medicine for Inflammation in Epithelial Barrier Damage in the Nose. A Perspective Mini Review. Allergy, Sec. Rhinology, Volume 3. https://doi.org/10.3389/falgy.2022.768408. Ciofalo, A. et al. Diagnostic performance of nasal cytology. European archives of oto- rhino-laryngology : official journal of the European Federation of Oto-Rhino- Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino- Laryngology - Head and Neck Surgery, [s. l.], v. 279, n. 5, p. 2451–2455, 2022. doi 10.1007/s00405-021-07044-5. References Dabelić, A. Respiratory Problems. In: South-Paul JE, Matheny SC, Lewis EL. eds. CURRENT Diagnosis & Treatment: Family Medicine, 5e. McGraw Hill; 2020. Accessed December 03, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2934&sectionid=247400317. DynaMed. Allergic Rhinitis. EBSCO Information Services. Accessed December 4, 2023. Retrieved from https://www-dynamed- com.ccnm.idm.oclc.org/condition/allergic-rhinitis. Israel E. Asthma. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. eds. Harrison's Principles of Internal Medicine, 21e. McGraw Hill; 2022. Accessed November 10, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=3095&sectionid=265455714. References Kendrick, J. (2022). eCPS chapter on Allergic Rhinitis. Accessed Nov 5, 2023. https://www-e-therapeutics-ca.ccnm.idm.oclc.org/search. Kishiyama, J.L., Chang, J.J., & Donovan, S.M. Disorders of the Immune System. In: Hammer GD, McPhee SJ. eds. Pathophysiology of Disease: An Introduction to Clinical Medicine, 8e. McGraw Hill; 2019. Accessed December 03, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2468&sectionid=198219961. Kozin, E.D. & Lustig, L.R. Allergic Rhinitis. In: Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR. eds. Current Medical Diagnosis & Treatment 2023. McGraw Hill; 2023. Accessed November 05, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=3212&sectionid=269164714. References Pols, D.H. et al. Atopic dermatitis, asthma and allergic rhinitis in general practice and the open population: a systematic review. Scand J Prim Health Care. 2016 Jun;34(2):143-50. doi: 10.3109/02813432.2016.1160629. Epub 2016 Mar 24. PMID: 27010253. Pullerits, T. et al. The triad of current asthma, rhinitis and eczema is uncommon among adults: Prevalence, sensitization profiles, and risk factors. Respiratory Medicine, 2021;Volume 176. https://doi.org/10.1016/j.rmed.2020.106250. Quillen, D.M. & Feller, D.B. (2006). Diagnosing rhinitis: allergic vs. nonallergic. Am Fam Physician, 73(9):1583-90. PMID: 16719251. References Savouré, M. et al. Worldwide prevalence of rhinitis in adults: A review of definitions and temporal evolution. Clin Transl Allergy. 2022 Mar;12(3):e12130. doi: 10.1002/clt2.12130. PMID: 35344304; PMCID: PMC8967272. Shah, S.B. & Emanuel, I.A. Nonallergic and Allergic Rhinitis. In: Lalwani AK. eds. Current Diagnosis & Treatment Otolaryngology—Head and Neck Surgery, 4e. McGraw Hill; 2020. Accessed November 05, 2023. https://accessmedicine- mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2744&sectionid=229671736. Shusterman, D.J. Upper Respiratory Tract Disorders. In: LaDou J, Harrison RJ. eds. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine, 6e. McGraw Hill; 2021. Accessed December 03, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=3065&sectionid=255652128. References Sierra-Heredia, C. et al. Aeroallergens in Canada: Distribution, Public Health Impacts, and Opportunities for Prevention. Int J Environ Res Public Health, 2018 Aug;15(8): 1577. Published online 2018 Jul 25. doi: 10.3390/ijerph15081577. Simpson, E.L. et al. (2019). Atopic Dermatitis. In: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, Orringer JS. eds. Fitzpatrick's Dermatology, 9e. McGraw Hill. Accessed December 07, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2570&sectionid=210417027. Small, P., Keith, P.K. & Kim, H. Allergic rhinitis. Allergy Asthma Clin Immunol 14 (Suppl 2), 51 (2018). https://doi.org/10.1186/s13223-018- 0280-7. References Speer, L. Nasal Polyps. In: Usatine, R.P., Smith, M.A., Mayeaux, Jr., E.J., Chumley, H.S. eds. The Color Atlas and Synopsis of Family Medicine, 3e. McGraw Hill; 2019. Accessed December 03, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=2547&sectionid=206778268. Sur, D.K.C. & Plesa, M.L. Chronic Nonallergic Rhinitis. Am Fam Physician. 2018 Aug 1;98(3):171-176. PMID: 30215894. Tuttle, K.L. & Boyce, J.A. Urticaria, Angioedema, and Allergic Rhinitis. In: Loscalzo, J., Fauci, A., Kasper, D., Hauser, S., Longo, D., & Jameson, J. eds. Harrison's Principles of Internal Medicine, 21e. McGraw Hill; 2022. Accessed December 06, 2023. https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=3095&sectionid=264533761. Wheeler, P.W. & Wheeler, S.F. Vasomotor rhinitis. Am Fam Physician. 2005 Sep 15;72(6):1057-62. PMID: 16190503.