Allergic rhinitis (AR) involves inflammation of the nasal mucous membrane. In a sensitized individual, allergic rhinitis occurs when inhaled allergenic materials contact mucous membranes and elicit a specific response mediated by immunoglobulin E (IgE). This acute response involves the release of inflammatory mediators and is characterized by sneezing, nasal itching, watery rhinorrhea, and often associated with nasal congestion. Itching of the throat, eyes, and ears frequently accompanies allergic rhinitis.
AR involves three stages
- Sensitization to a particular allergen(a)
- Early phase response
- late phase response The early phase response has symptoms that are similar to nonallergic Rhinitis (NAR). The major inflammatory mediator involved in the early response is histamine. Symptoms includes itching, sneezing, watery rhinorrhea, the eyes may be puffy and likely develop into AC (allergic conjunctivitis).
The last phase response occurs due to more inflammatory mediators being released. The patient in the late stage complains of congested nostrils. The nasal congestion does not affect the ethmoid, maxillary and frontal sinus. This helps to differentiate from Rhinosinusitis.
The patient may also experience central nervous system symptoms such as weakness, lethargy, and irritability since nasal congestion frequently disturbs sleep. Sneezing and nasal drainage also occur in this stage.
Notice that fever is not a common sign in AR
Nigeria does not have an accurate database of the epidemiology of AR. It is estimated to be within 7- 30%. However, AR is a global concern that is growing by the day. It is the fourth most common ailment necessitating a visit to a health care professional. Care should be taken to treat AR adequately as it is a risk factor to developing asthma and most persons with asthma also have AR.
It can be classified as mild or moderate-to-severe and persistent or intermittent each with its different type of allergen. Most times the mild AR is confused with Non allergic Rhinitis (NAR) or Rhinosinusitis.
A knowledge of the classification, patient symptomology, duration and past history can help.
Basically, the line of management is as follows in that order
- Allergen identification and avoidance
- Use of oral antihistamines (OAH)
3.use of Inhaled intranasal steroids (INCS)
- Use of inhaled intranasal AH and INCS
- Other therapies
For mild cases the second or third generation antihistamines are indicated. Cetirizine, levocetirizine, fexofenadine and loratadine all have well-documented clinical efficacy in treating AR in children and adults. If the patient complains of nasal congestion that especially limits sleep, the use of INCS should be considered. It can be used together with OAH. Epistaxis and headache is a common side effect of an INCS. The most common INCS is fluticasone furoate (Avamys®). Another example of INCS is Triamcinolone acetonide (Nasacort®). The use of INCS does not immediately stops the symptoms. It takes up to 48 hours for symptom resolution.
One study shows that less than 50% of healthcare professional know how to use INCS devices. Sharpen your skill by watching this video.
Combination Inhaled Intranasal Steroids and Intranasal Inhaled Antihistamines
A combination inhaled intranasal steroids and intranasal inhaled antihistamines available in the market is fluticasone propionate and azelastine HCl. It has better onset of action and effectiveness
Other therapies include use of Nasal decongestants, Leucotriene receptor antagonists, Warm compresses, Use of eucalyptus oil/other useful aromatic oils and oral sympathomimetic agents.
Use of Nasal decongestants
The common intranasal decongestant is Xylometazoline. It is formulated as a drop and a spray in strengths of 0.1% for adult and 0.05% for children. Common brands are
2.Otrivin spray and drops
It is important to know the correct use of the intranasal decongestant. The steps below outline the correct use.
1.Shake bottle well
- Look down
- Using right hand for left nostril put nozzle just inside nose aiming towards outside wall
- Squirt once or twice (2 different directions), depending on recommended dose
- Change hands and repeat for other side
- Breathe in gently through the nose
- Do not sniff
Use of leucotriene receptor antagonist
leucotriene receptor antagonist may be beneficial for patients with concomitant asthma
Oral decongestant to relieve nasal congestion can be used in the management of AR Eg: Pseudo ephedrine.
This is the last resort or first resort for those who don’t want Pharmacotherapy.