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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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