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from previous page to treatment in the long term . ASCIA defines the indications for immunotherapy in allergic rhinitis as :
• Severe symptoms
• Difficult-to-avoid allergen ( for example grass pollen )
• Medications do not help or have intolerable side-effects
• Patient preference is to avoid medications 17
In Australia , subcutaneous therapy is used more commonly than sublingual , whereas the opposite is true in Europe .
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Surgery Surgery does not play a role in the routine management of allergic rhinitis . A substantial majority of cases are well-managed with the medications and protocols detailed above . In a small subset of patients , inferior turbinoplasty , and even sinus surgery and polypectomy , may be beneficial if symptoms are recalcitrant to medical treatment or if there is associated sinus disease . The role of surgery in this setting is to enable or improve delivery of intranasal medications to the mucosa .
These options can be considered on referral to an ENT surgeon if treatment is unsuccessful after three months .
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Case study TESSA , 27 , presents to her GP complaining of bilateral nasal obstruction . She reports a ‘ head cold ’ six weeks prior , with sneezing , rhinorrhoea and intermittent nasal obstruction . She denies cough , wheeze , fevers or any other feature of a lower respiratory tract infection at the time . Tessa states that most of her symptoms have resolved , but the nasal congestion has worsened and she is finding this particularly troublesome when exercising .
When asked about a personal and family history of atopy , Tessa reports being told she is allergic to cats after some sort of skin test on her arm as a child . She recalls being troubled by allergies for many years . She hasn ’ t been in contact with animals since leaving home 10 years ago and has been symptom-free since then . She recently moved to a regional NSW town to start a new job .
Six weeks ago , she started an over-the-counter nasal spray ( oxymetazoline ), which improved her symptoms initially . She says that she had to increase the frequency of use and the number of sprays to achieve relief after four weeks of use . She purchased a different spray last week ( tramazoline ), which has not improved her symptoms .
Anterior rhinoscopy reveals
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very bulky inferior turbinates and no appreciable nasal airway . She passes minimal air down the left side only . The rest of her examination is unremarkable .
After education regarding the use of nasal decongestants , Tessa ’ s tramazoline is stopped and she starts intranasal budesonide .
Tessa returns for follow-up one month later and reports substantial improvement of her nasal congestion , but is again troubled by occasional rhinorrhoea and sneeze . Given her strong history of atopy , her treatment is escalated to intranasal azelastine and fluticasone
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. She is referred for skin-prick testing , which is positive for cat pelt , dust mites and several grass pollens .
To date she is well controlled on this medication .
This case illustrates the ease with which nasal decongestants can be abused , and the significant and relatively rapid improvement that cessation offers . Also illustrated is the fact that patients are often allergic to multiple indoor and outdoor allergens . It is likely that Tessa ’ s recent relocation exposed her to allergens responsible for her presentation .
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Summary IN the majority of patients , a thorough history and examination , along with skin-prick testing , is enough to confirm or exclude a diagnosis of allergic rhinitis and identify the offending allergen ( s ). Where the results of a skin-prick test is inconsistent with the history and examination , repeat or further testing can be considered , along with a therapeutic trial of pharmacotherapy .
Key points
• Allergic rhinitis is a common , potentially chronic hypersensitivity disorder with a clear genetic component .
• This condition is associated with an increased risk of incident asthma , and its treatment has been demonstrated to improve asthma and bronchial hypersensitivity .
• Allergen avoidance measures are not yet well supported by the literature and should be recommended WITH appropriate pharmacotherapy .
• Prolonged use of readily available over-the-counter nasal decongestants leads to rhinitis medicamentosa and should be considered in the differential diagnoses .
• Immunotherapy is a protracted treatment that requires long-term commitment from patient and physician .
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1 . Which TWO statements regarding allergic rhinitis are correct ? a ) Improperly treated , allergic rhinitis is a chronic disorder with a potentially significant disease burden . b ) Allergic rhinitis is a common , IgG-mediated inflammatory disorder of the nasopharyngeal mucosa that occurs in response to allergen exposure in prone individuals . c ) Females are slightly more affected compared with males . d ) Allergic rhinitis is noted at a steady prevalence across Australia .
2 . Which THREE stalemates regarding the classification of allergic rhinitis are correct ? a ) Allergic rhinitis is classified according to the persistence and duration of symptoms , and their severity . b ) Persistent allergic rhinitis is present for more than four days a week and for more than four weeks . c ) The ARIA 2001 classification reflects the fact that many patients are sensitised to more than one allergen and that many ‘ outdoor allergens ’ are seasonal . d ) One or more of a range of specific symptoms is required to make a diagnosis of moderate / severe allergic rhinitis .
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3 . Which TWO are factors in the aetiology of allergic rhinitis ? a ) Unhygienic home environment . b ) Maternal allergen exposure during pregnancy . c ) Genetics . d ) Occupational allergens .
4 . Which THREE statements the relationship between allergic rhinitis and asthma in are correct ? a ) There is no increased risk of asthma as an adult in children who have allergic rhinitis , as the link appears to exist only between adultonset allergic rhinitis and asthma . b ) The majority of patients with allergic rhinitis and asthma had symptoms of rhinitis first , or were diagnosed with both diseases within one year of each other . c ) Patients with allergic rhinitis but without asthma have greater bronchial hypersensitivity . d ) Treatment of allergic rhinitis has been shown to improve asthma symptoms and reduce bronchial hypersensitivity .
5 . Which TWO are cardinal symptoms of allergic rhinitis ? a ) Bilateral watery rhinorrhoea . b ) Postnasal drip .
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c ) Conjunctivitis . d ) Nasal obstruction .
6 . Which THREE are facial features associated with allergic rhinitis ?? a ) Nasal crease . b ) Beau ’ s lines . c ) Allergic salute . d ) Allergic shiners .
7 . Which THREE are differential diagnoses of allergic rhinitis ? a ) Rhinitis medicamentosa . b ) Viral rhinosinusitis c ) Vasomotor rhinitis . d ) Sinusitis .
8 . Which TWO statements regarding the investigation of allergic rhinitis are correct ? a ) Properly performed skin-prick testing is the gold standard in the diagnosis of allergic rhinitis . b ) A therapeutic trail may only be started once skin prick testing has confirmed the diagnosis of allergic rhinitis . c ) Patch testing is a useful adjuvant in the case of equivocal results on skin-prick testing . d ) Serum-total IgE plays no role in the routine
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investigation of isolated allergic rhinitis .
9 . Which TWO statements regarding the management of allergic rhinitis are correct ? a ) The role of aeroallergen avoidance is core in the management of allergic rhinitis . b ) Surgery does not play a role in the routine management of allergic rhinitis . c ) IV immunotherapy aims to ‘ switch off ’ the immune response to the offending allergen ( s ). d ) Aeroallergen avoidance and reduction do reduce measurable levels of allergens , but this effect does not correlate with clinical benefit .
10 . Which THREE statements regarding the medications to treat allergic rhinitis are correct ? a ) Montelukast is equivalent to H1- antihistamines in the treatment of allergic rhinitis . b ) Intranasal antihistamines are rapidly effective and generally well tolerated . c ) Do not exceed five ( preferably three ) days of use of intranasal decongestants . d ) First-generation oral antihistamines are preferred because of their greater tolerability and their lack of sedation .
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