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Home , Allergic rhinitis

with 20% of all pediatric visits being related.4 Table 2 provides some understanding of the constitution of these Complications of allergic visits. The inhaled are respon- sible for most rhinitis and other allergic JEFFREY W. GLASSHEIM, DO respiratory diseases. These are CHARLENE 0. LUND, RN, MS, CFNP usually derived from natural organic sub- stances, such as house dust , pol- lens, mold spores, and insect and animal hair, pelt, and saliva. Many have Although rhinitis is the most common manifestation of and affects millions, specific, recurrent seasons, while others it often goes untreated. It affects approximately 20% to 25% of the US population. are perennial. The pattern of seasonal Allergic rhinitis manifests the same tissue changes as found in the entire upper exposure in the Central San airway following interactions of inununoglobulin E and specific allergen(s). These Joaquin Valley region of California is tissue changes exhibit symptoms of the disease and preset responses to reexposure similar to that in the rest of the United to the same allergens. If allergic rhinitis is not given proper recognition and treat- States. Most tree pollens are released dur- ment, many complications may arise, induding sleep disturbances, otitis media, sinusi- ing early to midspring, and the height of tis, nasal polyps, and poor control of for those with concomitant disease. the grass season is late spring to It is better to prevent these complications than to treat them. Allergic rhinitis has early summer. Although some species of a great impact on patients health-related quality of life, an important "outcomes" weed pollen are airborne in spring and measure, and proper treatment of allergic rhinitis is reflected in that outcomes early summer, the greatest difficulty from measurement. weeds is in late summer and early fall. (Key words: allergen, allergic rhinitis, , health-related quality Despite popular belief, the heavy, sticky of life, , hyperresponsiveness, immunotherapy, leukotrienes, otitis media, pollens of brightly colored sel- prostaglandin) dom cause allergy symptoms, as these pollens are spread by insects and not by wind currents.5 The common misnomer hinitis, the general medical term for sure to the allergen(s) leads to a cascade " " relates to the season of rag- R..disorders of of the of events, including a rapid release of weed and grass pollenosis and is not asso- nasal passages, occurs more frequently mediators like and leukotrienes ciated with fever. than all other allergic disorders. Allergic from the , and others derived Major perennial allergens to be aware rhinitis is caused by an allergic reaction, from and lymphocytes. Aller- of include fungi, dust mites, cat pelt/hair, immunologic events manifested by nasal gic rhinitis has a clinically significant dog dander, and cockroaches. Although blockage and discharge. Symptoms, such impact on patients health-related quali- pollen allergens typically become wind- as sneezing, sniffling, runny nose, itchy ty of life, an important "outcomes" mea- borne during dry weather and are nose, and stuffiness, congestion, post- sure developed in the late 1990s.1 removed from the air during rain, high nasal drip, and drainage result. Allergic mold spore counts are found on cloudy, rhinitis refers to three types of nasal Epidemiology rainy, or foggy days (or a combination). inflammatory disorders caused by this Between 20% and 25 % of the US pop- Many of the upper aller- allergic response: ulation suffers from allergic rhinitis. Aller- gy symptoms occur during periods of q seasonal allergic rhinitis, gic rhinitis results in 28 million patient high humidity and are probably 111 perennial allergic rhinitis, and days of restricted activity, 6 million patient attributable to favorable conditions for q occupational allergic rhinitis. days of bed rest, 3 million patient days mold spore growth.6 Once an individual is sensitized, reexpo- lost from school, 5 million patient days Dust mites are a common allergen lost from work, as well as a $200 million worldwide. They are tiny, transparent loss in wages, and $500 million spent on acarids that thrive in bedding, carpets, Dr Glassheim is assistant clinical professor, This condition should be and upholstery. The principal species of Department of Pediatrics, University of Califor- healthcare.2 nia–San Francisco at Fresno, and assistant taken seriously by any managed care dust mites are the Dermatophagoides clinical professor, Department of Family Practice, organization attempting to control costs. farinae and the Dermatophagoides Western University of Health Sciences College pteronyssinus. They encase their fecal of Osteopathic Medicine of the Pacific, Pomona, The prevalence of the common allergic Calif. Ms Lund is a clinical associate, Universi- diseases are shown in Table 1.3 materials in a coating rich in intestinal ty of California–San Francisco at Fresno. Allergic rhinitis accounts for more enzymes, and it is a protease within this Correspondence to Jeffrey W. Glassheim, coating that is the primary allergen? They DO, 1646 E Herndon, Suite 106, Fresno, CA than 3% of all clinician office visits per 93720. year. In children, the number is greater, require a warm (>60°F to 70°F), humid

Glassheim and Lund • Complications of allergic rhinitis JAOA • Vol 98 • No 5 • Supplement to May 1998 • S1 portions of the trigeminal nerve. The Table 1 nasal glands and vasculature receive Prevalence of the Common Allergic Diseases3 parasympathetic input, causing vasodi- lation. They also receive sympathetic Allergic condition No. affected, in millions input, causing vasoconstriction. The sym- pathetic response is responsible for the q Allergic rhinitis —50 volume of blood in the cavernous sinus- q Asthma 20 to 25 with active disease es and also for the regulation of nasal 111 Chronic / 32 airflow. It is the pooling of blood in the inflammatory sinus disease sinuses, even more than the mucosal edema, that effects as we see it in allergic rhinitis. Table 2 The nasal mucosa is filled with numer- Constitution of Clinician Office Visits for Allergic Diseases ous glands below the surface, including both serous and mucous types. "A plexus No. of visits per year, of sinusoids lying deep in the glandular Reason for visit in millions tissue may engorge, causing nasal con- gestion."8 Just below the basement mem- q and eczema 5.8 brane lies a network of venules which is the primary target for mediators derived q 5.4 (for children) Allergy immunotherapy from the mast cell. q Allergic skin reactions 12.0 q and allergic 1.0 to 2.0 Pathogenesis reactions Kaliner and Lemanske3 wrote clearly of the pathogenesis of allergic rhinitis. The impact of allergens on the respiratory (>50% to 75% relative humidity) envi- that allergic rhinitis can act to exacer- tract mucous membranes comes from ronment to proliferate. Cat allergens, bate acute episodes of bronchial asthma. airborne foreign particles with each derived from both salivary and skin inhalation. Particulates the size of most sources, are much smaller and lighter Anatomy pollen grains and the larger mold spores than dust allergens and are found An appreciation of anatomy helps to are deposited on the nasal mucosa, and constantly in the air in households with understand the and only particles with an aerodynamic equiv- cats. Dog allergens are found in saliva, potential complications of allergic rhini- alent diameter of less than 2 nm to 4 nm skin dander, and urine. Cockroaches tis (Figure). Naclerio and Solomon gave are likely to reach the lower respiratory should be suspected in any perennially a concise anatomic account, much of tract. However, evidence indicates that in allergic patient living in or around a city. which is paraphrased here. The many addition to the intact pollen grains them- Exposure to perennial allergens—main- hairs found at the entrance to the nasal selves, pollen allergens are airborne in ly through inhalation but, in some cavity stop large particles from obstruct- much smaller particles and in even par- instances, by ingestion—accounts for ing the upper respiratory tract. The nasal ticle-free fractions of atmospheric mois- year-round allergies. valve accounts for up to 50% of the total ture that potentially can reach the lower Although allergic rhinitis can occur resistance to airflow between the anteri- respiratory tract. It is thought that water- at any age, it is most common in the or nostrils and the alveoli. The large sur- soluble allergens elute quickly from the young, active portion of the population. face area of the and antigen-containing particles and diffuse It occurs slightly more often in males turbinates found between the nostrils into the respiratory tract . than females until about age 55. It is promotes contact with inspired air, expe- After nasal challenges with allergen found more than twice as frequently in diting humidification, temperature con- in sensitive individuals, nasal washings patients with concomitant asthma as trol, and particle elimination. "The nose have shown prominent increases in the compared with those who have nonal- receives its blood supply from both the following mediators: histamine, esterase, lergic rhinitis.3 Over time, allergic rhini- internal and external carotid circulation leukotriene (LT), and prostaglandin D2 tis may predispose sufferers to the devel- via the ophthalmic and internal maxillary (PGD2), tryptase, kinins, and kininogen opment of sinusitis, serous otitis media arteries, respectively."8 activity.5 Histamine is thought to be the (SOM) with effusion, and nasal polypo- The nerve supply is mostly autonom- major mediator in acute allergic respons- sis. There is increasing evidence to support ic and sensory, thus nonadrenergic non- es. Both immediate and late-phase reac- the notion that allergic rhinitis predis- cholinergic. The sensory constituents tions are observed and, at both times, poses to the development of asthma, and come from the maxillary and ophthalmic there are increased concentrations of these

S2 • JAOA • Vol 98 • No 5 • Supplement to May 1998 Glassheim and Lund • Complications of allergic rhinitis of greater than or equal to 150 mm H20 may be found, or peak compliance may Frontal sinus be flat at impedance tympanometry, which indicates a serous effusion.3 Appro- Sella turcica priate treatment must therefore include Anterior that keep the nasal airway ethmoidal sinus Sphenoidal sinus patent. This need for maintenance of air- way patency is especially true, for exam- Posterior ple, during airplane flights. ethmoidal sinus Nasolacrimal Chronic sinusitis duct Maxillary sinus In children, symptoms of sinusitis include Eustachian tube chronic nasal discharge, persistent cough- opening ing (especially at night), and recurrent otitis media. Pain, headache, and fever occur less frequently, whereas in adults, these symptoms, along with purulent nasal discharge, are the most frequently Figure. Nasofrontal orifice and sinuses. recognized. The clinician should consid er treatment for sinusitis whenever: q symptoms of upper respiratory tract mediators, except for lack of PGD 2 in Obstructive dysfunction of the eustachi- infection or rhinitis are more protracted the late phase. The late-phase allergic an tube as a result of mucosal edema than expected; response is thought to be due to a com- and secretions can cause SOM. When q the patient has dull to intense throb- bination of mast cell–derived inflamma- allergic rhinitis causes nasal obstruction, bing pain over the involved sinus region; tory factors and , lymphocytes, it can lead to middle ear disease sec- q the patients asthma is not responding or other inflammatory cells. Because ondary to the Toynbee phenomenon. If appropriately to medications; or PGD2 is released by mast cells but not the eustachian tube opens during the pos- q the patient has prolonged or persistent , this latter observation strong- itive phase of closed-nose swallowing, that has failed to respond to ly suxests a possible role for basophils in allergic nasopharyngeal secretions could appropriate therapy. Whenever sinusitis nasal late-phase reactions.9 be insufflated into the middle ear, causing is diagnosed, the possibility of other The nasal mucosa responds to acute otitis media.10 Many times, however, underlying processes should be consid- allergic reactions with these changes: allergic factors cannot be identified. When ered.11 q increased vascular permeability involv- the edema is chronic, it can lead to hear- ing the subbasement membrane plexus of ing loss with resultant adverse effects on Nasal polyps vessels, resulting in the formation of speech development, cognition, or both, Although the exact pathogenesis of nasal subepithelial edema and the rapid pro- certainly factors affecting health-related polyps is not known, the two most fre- duction of albumin-rich secretions; quality-of-life issues. The young child is at quently mentioned theories are based on q increased glandular secretions from greatest risk for these latter complica- allergic and infectious causes.12 Related to the submucous glands consisting of a tions. allergies, polyps show degranulation of complex mixture of proteins; and A history of hearing loss, delayed mast cells and marked tissue - q pruritus and sneezing as reflex speech development, or recurrent otitis ia as well as elevated histamine and IgE responses. superimposed on chronic nasal obstruc- levels in extracellular polyp fluid. How- This acute response is followed by a tion are suggestive of the diagnosis of ever, there is growing evidence that aller- chronic inflammatory response, including SOM. At physical examination, a retract- gies have little impact on the etiologic neutrophil and eosinophil infiltration of ed, frequently amber-colored tympanic development of nasal polyps.12 the mucosa, mast cell hyperplasia, and membrane is seen. Decreased motion of increased basophils. The inflamed mucosa the tympanic membrane in the presence Asthma exacerbations becomes hyperresponsive to both anti- of negative middle ear pressure is revealed The frequent association of nasal and gen and nonspecific irritants. with use of pneumatic otoscopy. No paranasal sinus disease with bronchial motion at all may be seen if a serous asthma was first appreciated many years Complications effusion is present. Audiometry may ago. Reflex bronchoconstriction can result Serous otitis media reveal a conductive hearing loss that is from stimulation of receptors in the nose Serous otitis media can be a complication most pronounced in the lower frequencies and nasopharynx.13 Because of the poten- of allergic rhinitis, especially in children. (500 Hz to 2000 Hz). A peak compliance tial problems of allergic rhinitis leading to

Glassheim and Lund • Complications of allergic rhinitis JAOA • Vol 98 • No 5 • Supplement to May 1998 • S3 sinusitis, it is fair to say that allergic rhini- highly recommended. Carpeted floors or to treat significant nasal polyposis (or tis has an association in exacerbating are a reservoir for the dust mite and both). asthma. Boggs,2 in 1994, found that asth- should be discouraged. In addition, aca- Allergy immunotherapy should be ma develops in about 30% of persons ricide or tannic acid (or both) may be considered in patients with pollen, dust with allergic rhinitis. Bronchial hyperre- used to kill the mite and denature the mite, mold spore, cockroach, or animal sponsiveness, the principal cause of which protein allergen, respectively. However, dander allergies who: is thought to be airway inflammation, the need for and costs of retreatment q are not responding adequately to can be found in patients with asthma must be weighed against the potential pharmacotherapy; who have not wheezed for years or who benefits. q who require medications for more are asymptomatic.14 A more detailed dis- ■ Commercial spraying is the only mea- than 3 to 6 months of the year; or, cussion of bronchial asthma is beyond sure that has been shown to reduce cock- q who have complications develop from the scope of this article and would best be roach exposure. the pharmacotherapy. reviewed by consulting the 1997 revised New therapeutic additions to our To be effective, immunotherapy is national guidelines.15 armamentarium for treatment of aller- dependent on an adequate dose of the gic rhinitis are under study, and some respective allergen(s) and must be admin- Treatment have recently made their way into the istered for an appropriate length of time. Treatment of patients with rhinitis is market. The latest of these are: It is important to select for the most dependent on the correct diagnosis. Three q the leukotriene modifiers; appropriate dosage, concentration, and basic therapeutic techniques should be q more potent topical intranasal corti- specificity of antigen(s), as there may oth- considered in treating either seasonal or costeroids; and erwise be a recrudescence of symptoms perennial allergic rhinitis: q topical nasal . once is discon- q avoidance of the offending allergens; A general rule of thumb is to anticipate tinued.18 Immunotherapy is highly effec- q use of appropriate medications; and the onset of symptoms, and begin the tive in controlling symptoms of allergic q use of allergy immunotherapy. prophylactic use of to lessen rhinitis, sinus disease, and asthma. Selec- Some of the environmental control the impact of allergen exposure on the tion of candidates should be based on a measures include: patient. correlation between the allergenic con- ■ When indoor mold exposures are Antihistamines can reduce many tents of the extract material and the aller- considerable, installing a dehumidifier in symptoms of allergic rhinitis, but they gens that precipitate their symptoms. A a damp area may be helpful. Mold-sen- have little objective effect on nasal con- comprehensive and detailed history is of sitive patients generally should avoid gestion. Oral , such as pseu- the utmost importance. barns, hay, raking leaves, and mowing doephedrine or , grass. Use of a bleach solution works as can effectively decrease nasal congestion Reasons for referral well as any other commercially available but can also cause insomnia, loss of There are several reasons that primary product to remove fungi and mold in appetite, or excessive nervousness. care clinicians should consider referral damp areas.9 Driving in air-conditioned Intranasal corticosteroids are very effec- to an allergy/asthma/ spe- vehicles is preferable, and air-condition- tive in controlling symptoms of allergic cialist. These include: ing the house greatly reduces pollen in rhinitis, and studies show few systemic q clarification of allergic or other etio- the indoor air. Closing bedroom win- side effects as long as the patient is care- logic basis for the patients rhinitis; dows during the pollen season is useful. fully instructed in their proper use.17 q identification of triggers (allergic or ■ Camping and hiking are preferably Intranasal cromolyn sodium is also effec- not) responsible for the patients rhinitis; done at times other than during the pollen tive in some patients and has minimal q insufficient treatment due to inade- season. High-efficiency particulate air side effects. Intranasal anticholinergics quate efficacy; (HEPA) filters are useful in reducing air- may effectively reduce but q adverse reactions to medication(s); borne allergens in small spaces, such as a have no effect on nasal congestion. Most q impairment of the patients perfor- bedroom.14 It would be worthwhile to patients will respond to a combination of mance or health-related quality-of-life rent this equipment before buying it to an (H1- antago- issues (or both) as the result of manifes- ensure that symptomatic relief is obtained. nist) plus a topical intranasal corticoste- tations of allergic rhinitis; and finally, ■ Recent data suggest that weekly wash- roid with a rapid reduction in symptoms. q request by patients or parents of ing of the cat,16 when combined with Cromolyn sodium is an acceptable alter- patients. other avoidance measures, greatly reduces native, either alone or combined with an the "in-house" allergen load of Fel d 1, antihistamine, but it must be started "pre- Comment the major allergen in cat dander. season" to achieve optimal results. Final- The prevalence and severity of allergic ■ Plastic encasement of the house dust ly, a short course or "burst" of oral cor- rhinitis is increasing. A complete history, mite–sensitive patients bedding, includ- ticosteroid may be appropriate for the physical examination, and immediate ing pillow, mattress, and box spring, is treatment of intractable nasal symptoms skin tests will help to for-

S4 • JAOA • Vol 98 • No 5 • Supplement to May 1998 Glassheim and Lund • Complications of allergic rhinitis mulate the correct diagnosis. Newer med- ications allow physicians to tailor treat- ment to the patients specific condition and complaints. With proper and aggres- Chronic rhinosinusitis sive treatment, patients with allergic rhini- tis may have a significant increase in their SHASHI A.M. KUMAR, MD health-related quality of life. BRYAN L MARTIN, DO

References 1. Blaiss M. Outcomes analysis in asthma. JAM/ 1997;278:1874-1887. 2. Boggs P. Sneezing Your Head Off. Kenilworth, NJ: Schering Corporation, 1992. Chronic rhinosinusitis is a common inflammatory sinus disease; however, the 3. Kaliner M, Lemanske R. Rhinitis and asthma. In: deShazo, RD, editor. Primer on allergic and immunologic cause and the pathogenesis are not clearly understood. The histologic hallmark is diseases. JAMA 1992;268:2807-2829. marked tissue driven by cytokines derived from T lymphocytes. 4. Seargeant S. Allergy Free Living. Visalia, Calif: Seargeant Publishing Company Inc; 1997. Both aerobic and anaerobic bacteria are isolated from the sinus aspirates. Com- 5. Solomon WR, Mathews KP. Aerobiology and inhalant puted tomography and rhinoscopy may show associated anatomic abnormalities. allergens. In: Middleton EJ Jr, Reed CE, Ellis EF, Adkin- Surgery decreases symptoms and improves quality of life in the majority of son NF Jr, Yunginger JW, editors. Allergy: Principles and Practice, 3rd edition. St Louis, Mo: Mosby-Year patients who fail to respond to an adequate trial of medical therapy. Work is urgent- Book Co; 1988; pp 312-372. ly needed to clarify the pathogenesis and the role of infectious agents in initiating 6. Glassheim JW, Ledoux RA, Vaughan TR, Damiano MA, Goodman DL, Nelson JS, et al. Analysis of mete- or complicating the disease to allow more rational use of medical or surgical orologic variables and seasonal pollen management. counts in Denver, Colorado. Ann Allergy Asthma (Key words: rhinosinusitis, rhinitis, sinusitis, nasal discharge, nasal obstruc- Immunol 1995;75:149-156. 7. Kanthawatana S, Maturim W, Fooanan S, Trakulti- tion) vakom M. Skin prick reaction and nasal provocation response in diagnosis of nasal allergy to the house dust mite. Ann Allergy Asthma Immunology 1997;79:427- 430. hinosinusitis is a more appropri- q nasal discharge (often purulent), 8. Naderio R, Solomon W. Rhinitis and inhalant aller- q gens. JAMA 1997;278:1842-1848. Rate term to use than either rhinitis postnasal drip, 9. Naclerio RM., Allergic rhinitis. N Engl J Med or sinusitis for the following reasons: q nasal stuffiness, 1991;325:860-869. rhinitis typically precedes sinusitis, q headaches, 10. Bluestone CD, Fireman P. Otitis media In: Middle- ton EJ Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yungin- sinusitis without rhinitis is rare, the q facial fullness, ger JW, editors. Allergy: Principles and Practice. 3rd mucosa of the nose and sinuses are con- q sore throat, edition. St Louis, Mo: Mosby-Year Book Co; 1988; pp q 1305-1326. tiguous, and the symptoms of nasal cough, 11. Kaliner MA, Osguthorpe JD, Fireman P, Anon J, obstruction and nasal discharge are q decreased sense of smell and taste, Georgitis, J, Davis ML, et al. Sinusitis: Bench to bedside. prominent in sinusitis.1 q Current findings, future directions. J Allergy Clin Immunol fetid breath, 1997;99(6 Pt 3):S829-S848. Chronic rhinosinusitis is defined as q decreased hearing, 12. Slavin RG. Nasal polyps and sinusitis. JAMA inflammation of sinuses persisting for q tinnitus, 1997;278:1849-1854. q 13. Lemanske RF Jr, Busse \NW. Asthma. JAMA more than 8 to 12 weeks. The best def- fullness in ears, 1997;278:1855-1873. inition comes from a recent conference,1 q ear popping, 14. Smith JM. Epidemiology and natural history of asth- at which chronic rhinosinusitis was q ma, allergic rhinitis, and (eczema). In: exacerbation of asthma, and Middleton EJ Jr, Reed CE, Ellis EF, Adkinson NF Jr, defined as "persistent inflammation doc- q constitutional symptoms, including Yunginger JW, editors. Allergy: Principles and Practice. umented with imaging studies at least 4 dizziness, fatigue, and generalized 3rd edition. St Louis, Mo: Mosby-Year Book Co; 1988, pp 891-929. weeks after initiating appropriate med- malaise. 15.Expert Panel Report II: Guidelines for the Diagnosis ical therapy in the absence of an inter- and Management of Asthma Bethesda, Md: National Asthma Education and Prevention Program; National vening acute episode." The clinical diag- Impact on public health Institutes of Health; NIH publication 97-4051; 1997. nosis of chronic rhinosinusitis is difficult and quality-of-life issues 16.Avner DB, Perzanowski MS, Plaits-Mills TAE, Wood- because many patients have vague symp- Sinusitis is the most frequently reported fold JA. Evaluation of different techniques for washing cats: Quantitation of allergen removed from the cat and toms. They may have one or a combi- chronic disease in the United States, the effect on airborne Fel d I. J Allergy Clin Immunol nation of the following symptoms: ranking higher than arthritis, hyperten- 1997:100:307-312. 17. Pullerits T, Praks strand M, Rak S, Skoogh BE, sion, and allergies. It is the fifth leading Lotvall J. An intranasal glucccorticoki inhibits the increase Dr Kumar is in private practice in Huntsville, cause for use of antibiotics. The 1991 of specific IgE initiated during pollen season. J Ala, and Dr Martin is in private practice in San National Ambulatory Care Survey, 2 Allergy Clin Immunol 1997:100:601-605. a 18 VanMetre TE Jr, Adkinson NF Jr. Immunotherapy for Antonio, Tex. periodic national physician survey of Correspondence to Bryan L. Martin, DO, aeroallergen disease. In Middleton EJ Jr, Reed CE, patient visits to private physicians Ellis EF, Adkinson NF Jr, Yunginger JW, editors. Aller- Southwest Allergy Asthma Center, PA, 7711 gy: Principles and Practice. 3rd edition. St Louis, Mo: Louis Pasteur Dr, Suite 905, San Antonio, TX offices, reported 11.6 million visits for Mosby-Year Book Co; 1988; pp 1327-1343. 78229-3424. chronic rhinosinusitis. In 1992, 13 mil-

Kumar and Martin • Chronic rhinosinusitis JAOA • Vol 98 • No 5 • Supplement to May 1998 • S5