Allergic rhinitis

• Rhinitis is defined as inflammation of the nasal membranes and is characterized by a symptom complex that consists of any combination of the following: sneezing, nasal congestion, nasal itching, and rhinorrhea.

• The eyes, ears, sinuses, and throat can also be involved.

• Allergic rhinitis is very common cause of rhinitis.

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.

• The tendency to develop allergic, or IgE-mediated, reactions to extrinsic allergens (proteins capable of causing an allergic reaction) has a genetic component.

• In susceptible individuals, exposure to certain foreign proteins leads to allergic sensitization, which is characterized by the production of specific IgE directed against these proteins.

• This specific IgE coats the surface of mast cells, which are present in the nasal mucosa.

• When the specific protein (eg, a specific pollen grain) is inhaled into the nose, it can bind to the IgE on the mast cells, leading to immediate and delayed release of a number of mediators.

• The mediators that are immediately released include histamine, tryptase, chymase, kinins, and heparin.

• The mast cells quickly synthesize other mediators, including leukotrienes and prostaglandin D2.

• These mediators, via various interactions, ultimately lead to the symptoms of rhinorrhea (ie, nasal congestion, sneezing, itching, redness, tearing, swelling, ear pressure, postnasal drip).

• Mucous glands are stimulated, leading to increased secretions. Vascular permeability is increased, leading to plasma exudation.

• Vasodilation occurs, leading to congestion and pressure. • Sensory nerves are stimulated, leading to sneezing and

itching. • All of these events can occur in minutes; hence, this reaction

is called the early, or immediate, phase of the reaction.

• Over 4-8 hours, these mediators, through a complex interplay of events, lead to the recruitment of other inflammatory cells to the mucosa, such as neutrophils, eosinophils, lymphocytes, and macrophages.

• This results in continued inflammation, termed the late-phase response.

• The symptoms of the late-phase response are similar to those of the early phase, but less sneezing and itching and more congestion and mucus production tend to occur.

• The late phase may persist for hours or days.

         A number of complications that can lead to increased morbidity or even mortality can occur secondary to allergic rhinitis. Possible complications include otitis media, eustachian tube dysfunction, acute sinusitis, and chronic sinusitis.

         Allergic rhinitis can be associated with a number of comorbid conditions, including asthma, atopic dermatitis, and nasal polyps. Evidence now suggests that uncontrolled allergic rhinitis can actually worsen the inflammation associated with asthma or atopic dermatitis. This could lead to further morbidity and even mortality.

         Allergic rhinitis can frequently lead to significant impairment of quality of life. Symptoms such as fatigue, drowsiness (due to the disease or to medications), and malaise can lead to impaired work and school performance, missed school or work days, and traffic accidents. The overall cost (direct and indirect) of allergic rhinitis was recently estimated to be $5.3 billion per year.

History:• Symptoms and chronicity

• Trigger factors

• Response to treatment

• Comorbid conditions

• Family history

• Environmental and occupational exposure

• Effects on quality of life

Symptoms and chronicity• Determine the age of onset of symptoms and whether symptoms have been present

continuously since onset. While the onset of allergic rhinitis can occur well into adulthood, most patients develop symptoms by age 20 years.

• Determine the time pattern of symptoms and whether symptoms occur at a consistent level throughout the year (ie, perennial rhinitis), only occur in specific seasons (ie, seasonal rhinitis), or a combination of the two. During periods of exacerbation, determine whether symptoms occur on a daily basis or only on an episodic basis. Determine whether the symptoms are present all day or only at specific times during the day.

• Determine which organ systems are affected and the specific symptoms. Some patients have exclusive involvement of the nose, while others have involvement of multiple organs. Some patients primarily have sneezing, itching, tearing, and watery rhinorrhea (the classic hayfever presentation), while others may only complain of congestion. Significant complaints of congestion, particularly if unilateral, might suggest the possibility of structural obstruction, such as a polyp, foreign body, or deviated septum.

Trigger factors o        Determine whether symptoms are related temporally to

specific trigger factors. This might include exposure to pollens outdoors, mold spores while doing yard work, specific animals, or dust while cleaning the house.

o        Irritant triggers such as smoke, pollution, and strong smells can aggravate symptoms in a patient with allergic rhinitis. These are also common triggers of vasomotor rhinitis. Many patients have both allergic rhinitis and vasomotor rhinitis.

o        Other patients may describe year-round symptoms that do not appear to be associated with specific triggers. This could be consistent with nonallergic rhinitis, but perennial allergens, such as dust mite or animal exposure, should also be considered in this situation. With chronic exposure and chronic symptoms, the patient may not be able to associate symptoms with a particular trigger.

Response to treatment • o        Response to treatment with antihistamines

supports the diagnosis of allergic rhinitis, although sneezing, itching, and rhinorrhea associated with nonallergic rhinitis can also improve with antihistamines.

• o        Response to intranasal corticosteroids supports the diagnosis of allergic rhinitis, although some cases of nonallergic rhinitis (particularly the nonallergic rhinitis with eosinophils syndrome [NARES]) also improve with nasal steroids.

Comorbid conditions • o        Patients with allergic rhinitis may have other atopic conditions such as

asthma or atopic dermatitis. Of patients with allergic rhinitis, 20% also have symptoms of asthma. Uncontrolled allergic rhinitis may cause worsening of asthma or even atopic dermatitis. Explore this possibility when obtaining the patient history.

• o        Look for conditions that can occur as complications of allergic rhinitis. Sinusitis occurs quite frequently. Other possible complications include otitis media, sleep disturbance or apnea, dental problems (overbite), and palatal abnormalities. The treatment plan might be different if one of these complications is present. Nasal polyps occur in association with allergic rhinitis, although whether allergic rhinitis actually causes polyps remains unclear. Polyps may not respond to medical treatment and might predispose a patient to sinusitis or sleep disturbance (due to congestion).

• o        Investigate past medical history, including other current medical conditions. Diseases such as hypothyroidism or sarcoidosis can cause nonallergic rhinitis. Concomitant medical conditions might influence the choice of medication.

Family history

o        Because allergic rhinitis has a significant genetic component, a positive family history for atopy makes the diagnosis more likely.

o        In fact, a greater risk of allergic rhinitis exists if both parents are atopic than if one parent is atopic. However, the cause of allergic rhinitis appears to be multifactorial, and a person with no family history of allergic rhinitis can develop allergic rhinitis.

Environmental and occupational exposure

o        A thorough history of environmental exposures helps to identify specific allergic triggers. This should include investigation of risk factors for exposure to perennial allergens (eg, dust mites, mold, pets). Risk factors for dust mite exposure include carpeting, heat, humidity, and bedding that does not have dust mite–proof covers. Chronic dampness in the home is a risk factor for mold exposure. A history of hobbies and recreational activities helps determine risk and a time pattern of pollen exposure.

o        Ask about the environment of the workplace or school. This might include exposure to ordinary perennial allergens (eg, mites, mold, pet dander) or unique occupational allergens (eg, laboratory animals, animal products, grains and organic materials, wood dust, latex, enzymes).

Effects on quality of life

• o        An accurate assessment of the morbidity of allergic rhinitis cannot be obtained without asking about the effects on the patient's quality of life. Specific validated questionnaires are available to help determine effects on quality of life.

• o        Determine the presence of symptoms such as fatigue, malaise, drowsiness (which may or may not be related to medication), and headache.

• o        Investigate sleep quality and ability to function at work.

Physical:

The physical examination should focus on the nose, but examination of facial features, eyes, ears, oropharynx, neck, lungs, and skin is also important. Look for physical findings that may be consistent with a systemic disease that is associated with rhinitis.

Physical:

         General facial features         Nose         Ears, eyes, and oropharynx         Neck         Lungs         Skin         Other

NoseThe nasal examination is best accomplished with a nasal speculum or an otoscope with nasal adapter. In the specialist's office, a rigid or flexible rhinolaryngoscope may be used.The mucosa of the nasal turbinates may be swollen (boggy) and have a pale, bluish-gray color. Some patients may have predominant erythema of the mucosa, which can also be observed with rhinitis medicamentosa, infection, or vasomotor rhinitis. While pale, boggy, blue-gray mucosa is typical for allergic rhinitis, mucosal examination findings cannot definitively distinguish between allergic and nonallergic causes of rhinitis.Assess the character and quantity of nasal mucus. Thin and watery secretions are frequently associated with allergic rhinitis, while thick and purulent secretions are usually associated with sinusitis; however, thicker, purulent, colored mucus can also occur with allergic rhinitis.Examine the nasal septum to look for any deviation or septal perforation, which may be present due to chronic rhinitis, granulomatous disease, cocaine abuse, prior surgery, topical decongestant abuse, or, rarely, topical steroid overuse.Examine the nasal cavity for other masses such as polyps or tumors. Polyps are firm gray masses that are often attached by a stalk, which may not be visible. After spraying a topical decongestant, polyps do not shrink, while the surrounding nasal mucosa does shrink.

Ears, eyes, and oropharynx o        Perform otoscopy to look for tympanic membrane retraction, air-fluid

levels, or bubbles. Performing pneumatic otoscopy can be considered to look for abnormal tympanic membrane mobility. These findings can be associated with allergic rhinitis, particularly if eustachian tube dysfunction or secondary otitis media is present.

o        Ocular examination may reveal findings of injection and swelling of the palpebral conjunctivae, with excess tear production. Dennie-Morgan lines (prominent creases below the inferior eyelid) are associated with allergic rhinitis.

o        The term “cobblestoning" is used to describe streaks of lymphoid tissue on the posterior pharynx, which is commonly observed with allergic rhinitis. Tonsillar hypertrophy can also be observed. Malocclusion (overbite) and a high-arched palate can be observed in patients who breathe from their mouths excessively.

         Neck: Look for evidence of lymphadenopathy or thyroid disease.

         Lungs: Look for the characteristic findings of asthma.

         Skin: Evaluate for possible atopic dermatitis.

         Other: Look for any evidence of systemic diseases that may cause rhinitis (eg, sarcoidosis, hypothyroidism, immunodeficiency, ciliary dyskinesia syndrome, other connective tissue diseases).

Causes:

The causes of allergic rhinitis may differ depending on whether the symptoms are seasonal, perennial, or sporadic/episodic. Some patients are sensitive to multiple allergens and can have perennial allergic rhinitis with seasonal exacerbations. While food allergy can cause rhinitis, particularly in children, it is rarely a cause of allergic rhinitis in the absence of gastrointestinal or skin symptoms.

Pollens (tree, grass, and weed)         Tree pollens, which vary by geographic location, are typically present in high counts

during the spring, although some species produce their pollens in the fall. Common tree families associated with allergic rhinitis include birch, oak, maple, cedar, olive, and elm.

        Grass pollens also vary by geographic location. Most of the common grass species are associated with allergic rhinitis, including Kentucky bluegrass, orchard, redtop, timothy, vernal, meadow fescue, Bermuda, and perennial rye. A number of these grasses are cross-reactive, meaning that they have similar antigenic structures (ie, proteins recognized by specific IgE in allergic sensitization). Consequently, a person who is allergic to one species is also likely to be sensitive to a number of other species. The grass pollens are most prominent from the late spring through the fall but can be present year-round in warmer climates.

        Weed pollens also vary geographically. Many of the weeds, such as short ragweed, which is a common cause of allergic rhinitis in much of the United States, are most prominent in the late summer and fall. Other weed pollens are present year-round, particularly in warmer climates. Common weeds associated with allergic rhinitis include short ragweed, western ragweed, pigweed, sage, mugwort, yellowdock, sheep sorrel, English plantain, lamb's quarters, and Russian thistle.

Outdoor molds Atmospheric conditions can affect the growth and dispersion of a number of molds; therefore, their airborne prevalence may vary depending on climate and season.

For example, Alternaria and Cladosporium are particularly prevalent in the dry and windy conditions of the Great Plains states, where they grow on grasses and grains. Their dispersion often peaks on sunny afternoons. They are virtually absent when snow is on the ground in winter, and they peak in the summer months and early fall.

Aspergillus and Penicillium can be found both outdoors and indoors (particularly in humid households), with variable growth depending on the season or climate. Their spores can also be dispersed in dry conditions.

Perennial allergic rhinitis is typically caused by allergens within the home but can also be caused by outdoor allergens that are present year-round. In warmer climates, grass pollens can be present throughout the year. In some climates, individuals may be symptomatic due to trees and grasses in the warmer months and molds and weeds in the winter.

House dust mites   2 major house dust mite species are associated with

allergic rhinitis. These are Dermatophagoides farinae and Dermatophagoides pteronyssinus. These mites feed on organic material in households, particularly the skin that is shed from humans and pets. They can be found in carpets, upholstered furniture, pillows, mattresses, comforters, and stuffed toys. While they thrive in warmer temperatures and high humidity, they can be found year-round in many households. On the other hand, dust mites are rare in arid climates.

Pets • Allergy to indoor pets is a common

cause of perennial allergic rhinitis.

• Cat and dog allergies are encountered most commonly in allergy practice, although allergy has been reported to occur with most of the furry animals and birds that are kept as indoor pets.

o        Cockroaches: While cockroach allergy is most frequently considered a cause of asthma, particularly in the inner city, it can also cause perennial allergic rhinitis in infested households.

o        Rodents: Rodent infestation may be associated with allergic sensitization.

Sporadic allergic rhinitis         Intermittent brief episodes of allergic rhinitis, is caused

by intermittent exposure to an allergen. Often, this is due to pets or animals to which a person is not usually exposed. Sporadic allergic rhinitis can also be due to pollens, molds, or indoor allergens to which a person is not usually exposed. While allergy to specific foods can cause rhinitis, an individual affected by food allergy also usually has some combination of gastrointestinal, skin, and lung involvement. In this situation, the history findings usually suggest an association with a particular food. Watery rhinorrhea occurring shortly after eating may be vasomotor (and not allergic) in nature, mediated via the vagus nerve (This often is called gustatory rhinitis.).

Occupational allergic rhinitis          is caused by exposure to allergens in the workplace, can

be sporadic, seasonal, or perennial. People who work near animals (eg, veterinarians, laboratory researchers, farm workers) might have episodic symptoms when exposed to certain animals, daily symptoms while at the workplace, or even continual symptoms (which can persist in the evenings and weekends with severe sensitivity due to persistent late-phase inflammation). Some workers who may have seasonal symptoms include farmers, agricultural workers (exposure to pollens, animals, mold spores, and grains), and other outdoor workers. Other significant occupational allergens that may cause allergic rhinitis include wood dust, latex (due to inhalation of powder from gloves), acid anhydrides, glues, and psyllium (eg, nursing home workers who administer it as medication).

Problems to be Considered: Vasomotor rhinitisGustatory rhinitis (vagally mediated)Rhinitis medicamentosa (eg, due to topical decongestants, antihypertensives, cocaine abuse)Hormonal rhinitis (eg, related to pregnancy, hypothyroidism, oral contraceptive use)Anatomic rhinitis (eg, deviated septum, choanal atresia, adenoid hypertrophy, foreign body, nasal tumor)NARES Immotile cilia syndrome (ciliary dyskinesis)Cerebrospinal fluid leakNasal polypsGranulomatous rhinitis (eg, Wegener granulomatosis, sarcoidosis)

Lab Studies: Allergy skin tests In vitro allergy tests, (RAST) Testing every patient for sensitivity to every allergen known is not

practical. Therefore, select a limited number of allergens for testing (this applies to both skin testing and RAST). When selecting allergens, select from among the allergens that are present locally and are known to cause clinically significant allergic disease. A clinician who is specifically trained in allergy testing should select allergens for testing.

Total serum IgETotal blood eosinophil count

Imaging Studies

• Radiography – Sinus films– Neck films

• CT scanning

• MRI

         CT scanning: Coronal CT scan images of the sinuses can be very helpful for evaluating acute or chronic sinusitis. In particular, obstruction of the osteomeatal complex (a confluence of drainage channels from the sinuses) can be seen quite clearly. CT scanning may also help delineate polyps, turbinate swelling, septal abnormalities (eg, deviation), and bony abnormalities (eg, concha bullosa).

         MRI: For evaluating sinusitis, MRI images are generally less helpful than CT scan images, largely because the bony structures are not seen as clearly on MRI images. However, soft tissues are visualized quite well, making MRI images helpful for diagnosing malignancies of the upper airway.

Nasal cytology

A nasal smear can sometimes be helpful for establishing the diagnosis of allergic rhinitis. A sample of secretions and cells is scraped from the surface of the nasal mucosa using a special sampling probe. Secretions that are blown from the nose are not adequate. The presence of eosinophils is consistent with allergic rhinitis but also can be observed with NARES. Results are neither sensitive nor specific for allergic rhinitis and should not be used exclusively for establishing the diagnosis.

Procedures: • Rhinoscopy

• Nasal provocation (allergen challenge) testing

Rhinoscopy

         While not routinely indicated, upper airway endoscopy (rhinolaryngoscopy) can be performed if a complication or comorbid condition may be present. It can be helpful for evaluating structural abnormalities (eg, polyps, adenoid hypertrophy, septal deviation, masses, foreign bodies) and chronic sinusitis (by visualizing the areas of sinus drainage).

Nasal provocation (allergen challenge) testing

This procedure is essentially a research tool and is rarely indicated in the routine evaluation of allergic rhinitis. The possible allergen is inhaled or otherwise inoculated into the nose. The patient can then be monitored for development of symptoms or production of secretions, or objective measurements of nasal congestion can be taken. Some consider this test the criterion standard test for the diagnosis of allergic rhinitis. However, it is not a practical test to perform routinely, and only an appropriately trained specialist should perform this test.

The management of allergic rhinitis consists of 3 major categories of treatment,

(1) environmental control measures and allergen avoidance,

(2) pharmacological management,

(3) immunotherapy

Environmental control measures and allergen avoidance

         These involve both the avoidance of known allergens (substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, or irritant, triggers. Consider environmental control measures, when practical, in all cases of allergic rhinitis. However, global environmental control without identification of specific triggers is inappropriate.

Pollens and outdoor molds          Because of their widespread presence in the outdoor air, pollens can be

difficult to avoid. Reduction of outdoor exposure during the season in which a particular type of pollen is present can be somewhat helpful. In general, tree pollens are present in the spring, grass pollens from the late spring through summer, and weed pollens from late summer through fall, but exceptions to these seasonal patterns exist.

         Pollen counts tend to be higher on dry, sunny, windy days. Outdoor exposure can be limited during this time, but this may not be reliable because pollen counts can also be influenced by a number of other factors. Keeping the windows and doors of the house and car closed as much as possible during the pollen season (with air conditioning, if necessary, on recirculating mode) can be helpful. Taking a shower after outdoor exposure can be helpful by removing pollen that is stuck to the hair and skin.

         Despite all of these measures, patients who are allergic to pollens usually continue to be symptomatic during the pollen season and usually require some other form of management. As with pollens, avoidance of outdoor/seasonal molds may be difficult.

Indoor allergens Depending on the allergen, environmental control measures for indoor allergens can be quite helpful. For dust mites, covering the mattress and pillows with impermeable covers helps reduce exposure. Bed linens should be washed every 2 weeks in hot (at least 130°F) water to kill any mites present. Thorough and efficient vacuum cleaning of carpets and rugs can help, but, ultimately, carpeting should be removed. The carpet can be treated with one of a number of chemical agents that kill the mites or denature the protein, but the efficacy of these agents does not appear to be dramatic. Dust mites thrive when indoor humidity is above 50%, so dehumidification, air conditioning, or both is helpful. Indoor environmental control measures for mold allergy focus on reduction of excessive humidity and removal of standing water. The environmental control measures for dust mites can also help reduce mold spores. For animal allergy, complete avoidance is the best option. For patients who cannot, or who do not want to, completely avoid an animal or pet, confinement of the animal to a noncarpeted room and keeping it entirely out of the bedroom can be of some benefit. Cat allergen levels in the home can be reduced with high-efficiency particulate air (HEPA) filters and by bathing the cat every week (although this may be impractical). Cockroach extermination may be helpful for cases of cockroach sensitivity.

• o        Occupational allergens: As with indoor allergens, avoidance is the best measure. When this is not possible, a mask or respirator might be needed.

• o        Nonspecific triggers: Exposure to smoke, strong perfumes and scents, fumes, rapid changes in temperature, and outdoor pollution can be nonspecific triggers in patients with allergic rhinitis. Consider avoidance of these situations or triggers if they seem to aggravate symptoms.

Immunotherapy (desensitization) A considerable body of clinical research has

established the effectiveness of high-dose allergy shots in reducing symptoms and medication requirements. Success rates have been demonstrated to be as high as 80-90% for certain allergens. It is a long-term process; noticeable improvement is often not observed for 6-12 months, and, if helpful, therapy should be continued for 3-5 years. Immunotherapy is not without risk because severe systemic allergic reactions can sometimes occur. For these reasons, carefully consider the risks and benefits of immunotherapy in each patient and weigh the risks and benefits of immunotherapy against the risks and benefits of the other management options.

Immunotherapy o        Indications: Immunotherapy may be considered more strongly

with severe disease, poor response to other management options, and the presence of comorbid conditions or complications. Immunotherapy is often combined with pharmacotherapy and environmental control.

o        Administration: Administer immunotherapy with allergens to which the patient is known to be sensitive and that are present in the patient's environment (and cannot be easily avoided). The value of immunotherapy for pollens, dust mites, and cats is well established. The value of immunotherapy for dogs and mold is less well established.

o        Contraindication: A number of potential contraindications to immunotherapy exist and need to be considered. Immunotherapy should only be performed by individuals who have been appropriately trained, who institute appropriate precautions, and who are equipped for potential adverse events.

Surgical Care

Surgical care is not indicated for allergic rhinitis but may be indicated for comorbid or complicating conditions, such as chronic sinusitis, severe septal deviation (causing severe obstruction), nasal polyps, or other anatomical abnormalities. The value of turbinectomy is not established.

Second-generation antihistamines

Often referred to as the nonsedating antihistamines. They compete with histamine for histamine receptor type 1 (H1) receptor sites in the blood vessels, GI tract, and respiratory tract, which in turn inhibits physiologic effects that histamine normally induces at the H1 receptor sites. Some do not appear to produce clinically significant sedation at usual doses, while others have a low rate of sedation. Other adverse effects (eg, anticholinergic symptoms) are generally not observed.

cetirizine, desloratadine, fexofenadine, and loratadine

Leukotriene receptor antagonists

Alternative to oral antihistamine to treat allergic rhinitis. One of the leukotriene receptor antagonists, montelukast (Singulair), has been approved in the United States for treatment of seasonal allergic rhinitis. When used as single agent, produces modest improvement in allergic rhinitis symptoms.

First-generation antihistamines

The older, first-generation H1 antagonists (eg, diphenhydramine, hydroxyzine) are effective in reducing most symptoms of allergic rhinitis, but they produce a number of adverse effects (eg, drowsiness, anticholinergic effects). They can be used prn, but adverse effects may limit their usefulness when taken on a daily basis. Some patients tolerate the adverse effects with prolonged use, but they may experience cognitive impairment, and driving skills may be affected. Administration at bedtime may help with drowsiness, but sedation and impairment of cognition may continue until the next day.

Decongestants

Stimulate vasoconstriction by directly activating alpha-adrenergic receptors of the respiratory mucosa. Pseudoephedrine produces weak bronchial relaxation (unlike epinephrine or ephedrine) and is not effective for treating asthma. Increases heart rate and contractility by stimulating beta-adrenergic receptors. Used alone or in combination with antihistamines to treat nasal congestion. Anxiety and insomnia may occur. Expectorants may thin and loosen secretions, although experimental evidence for their efficacy is limited. Numerous preparations are available containing combinations of various decongestants, expectorants, or antihistamines. Alternatively, a separate decongestant and antihistamine can be administered to allow for individual dose titration of each drug.

Nasal corticosteroids

Nasal steroid sprays are highly efficacious in treating allergic rhinitis. They control the 4 major symptoms of rhinitis (ie, sneezing, itching, rhinorrhea, congestion). They are effective as monotherapy, although they do not significantly affect ocular symptoms. Studies have shown nasal steroids to be more effective than monotherapy with nasal cromolyn or antihistamines. Greater benefit may occur when nasal steroids are used with other classes of medication. They are safe to use and not associated with significant systemic adverse effects in adults (this may also be true for children, but the data are less clear).

Nasal corticosteroids

Local adverse effects are limited to minor irritation or nasal bleeding, which resolve with temporary discontinuation of the medication. Nasal septal perforations are rarely reported and are less common with the newer corticosteroids and delivery systems. Safety during pregnancy has not been established; however, clinical experience suggests nasal corticosteroids (particularly beclomethasone, which has most experience in use) are not associated with adverse fetal effects. The nasal steroids can be used prn, but seem to be maximally effective when used on a daily basis as maintenance therapy. They may also be helpful for vasomotor rhinitis or mixed rhinitis (a combination of vasomotor and allergic rhinitis) and can help to control nasal polyps.

Intranasal cromolyns

Produce mast cell stabilization and antiallergic effects that inhibit degranulation of mast cells. Have no direct anti-inflammatory or antihistaminic effects. Effective for prophylaxis. May be used just before exposure to a known allergen (eg, animal, occupational). Begin treatment 1-2 wk before pollen season and continue daily to prevent seasonal allergic rhinitis. Effect is modest compared with that of intranasal corticosteroids. Excellent safety profile and are thought to be safe for use in children and pregnancy.

Intranasal anticholinergic agents

Used for reducing rhinorrhea in patients with allergic or vasomotor rhinitis. No significant effect on other symptoms. Can be used alone or in conjunction with other medications. In the United States, ipratropium bromide (Atrovent Nasal Spray) is available in a concentration of 0.03% (officially indicated for treatment of allergic and nonallergic rhinitis) and 0.06% (officially indicated for the treatment of rhinorrhea associated with common cold). The 0.03% strength is discussed.

Medical/Legal Pitfalls

o        While patients with allergic rhinitis may experience sedation and fatigue secondary to the disease process itself, sedation may occur due to medications. Most commonly, sedation is related to antihistamines, particularly the first-generation agents. In many states, driving while taking a first-generation, or sedating, antihistamine is illegal. Caution any patient who is taking a medication that has potential sedative effects about driving and operating heavy machinery.

o        A potential area of medicolegal concern is the failure to diagnose a comorbid condition or complication. Allergic rhinitis can occur in conjunction with other atopic diseases, such as asthma. Because asthma can be severe and even fatal, failure to diagnose concomitant asthma can lead to serious adverse events. Failure to diagnose potentially serious medical conditions that should be considered in the differential diagnosis of allergic rhinitis (eg, intranasal malignancy) might lead to serious consequences. Also, complications of allergic rhinitis (eg, sinusitis) can be serious and must be recognized when present.