Rhinitis Disease

DESCRIPTION

Immediate and delayed reactions to airborne allergens, beginning with the generation and presence of specific antigen-responsive IgE antibody receptors on mast cells of the nasal mucosa

An antigen-antibody chemical union initiates a cascade of events in the mast cell culminating in its degranulation and production of a melange of inflammatory mediators including histamine, heparin, leukotrienes, prostaglandins, proteases and platelet activating factor
An immediate symptomatic response occurs followed by a more prolonged, persistent late phase reaction. This involves the infiltration into the reactive region of eosinophils, neutrophils, basophils and mononuclear cells
May be seasonal or perennial depending on climate and individual response and the offending antigens
Seasonal responses usually to grasses, trees and weeds
Perennial responses usually house dust mites, mold antigens and animal body products
System(s) affected: Pulmonary, Skin/Exocrine, Hemic/Lymphatic/Immunologic
Genetics: Complex, but strong genetic determination present
Incidence/Prevalence in USA: 8-12% of the population affected
Predominant age:
- Onset usually before the age of 30 with tendency to diminish with time
- Mean age onset approximately 10 years
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Nasal stuffiness and congestion
Pale, boggy mucous membranes
Nasal polyps
Sneezing, often paroxysmal
Watery eyes
Dark circles under eyes, "allergic shiners"
Long eyelashes often associated
Sensation of plugged ears
Symptoms associated with sleeping difficulties
Fatigue
Mouth breathing
Scratchy throat
Voice change
Irritating cough
Postnasal drip
Loss or alteration of smell
Itchy nose, eyes, ears, and palate
Transverse nasal crease from rubbing nose upwards
Dull facies

CAUSES

Animal and plant proteins: Pollens, molds, mite dust, animal danders, dried saliva and urine
Insect debris: Cockroach, locusts, fish food (thrips)

RISK FACTORS

Family history
Repeated exposure to offending antigen
Exposure to multiple offending allergens
Presence of other allergies, e.g., atopic dermatitis, asthma, urticaria
Non-compliance to appropriate therapeutic measures

LABORATORY

CBC with differential. May have slight increase in eosinophils but often normal with uncomplicated rhinitis.
Nasal probe smear with cytologic exam for eosinophils
Increased IgE level. May do RAST determinations for specific suspected allergens.

Drugs that may alter lab results: Corticosteroids will ablate eosinophilia
Disorders that may alter lab results:

Secondary infections may alter differential and decrease nasal eosinophils
Parasitic infestations with more marked eosinophilia

PATHOLOGICAL FINDINGS

Nasal washing/scraping
- Eosinophils predominate
- Basophils
- May see mast cells
Nasal mucosa
- Submucosal edema but intact without evidence of destruction
- Eosinophilic infiltration
- Granulocytes to lesser extent
- Increased amount of tissue water with poor staining of ground substance
- Congested mucous glands and goblet cells

SPECIAL TESTS

Skin tests using suspected antigens Either technique manifests a positive reaction by inducing an expanding wheal and flare reaction. Special training recommended and available treatment for anaphylaxis mandatory.
- Scratch or prick: a superficial injury to the epidermis with application of diluted test antigen
- Intradermal: Introduction of diluted material between layers of skin raising a 4 mm wheal using a 25 or 27 gauge needle
Radioallergosorbent test (RAST)
- More expensive and used especially in cases where skin testing not practical, e.g., in atopic dermatitis and dermatographia
Audiometry
- For deficits and baseline evaluation
- Rhinoscopy (optional) - Excellent visual advantages

IMAGING

Sinus film when indicated. Check for complete opacity, fluid level and mucosal thickening.

DIAGNOSTIC PROCEDURES

See special lab tests. Appropriate diagnostic prick test kits available.

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Patient education, assurance, and understanding important
Limit exposure to offending allergen
Try to establish specific cause(s) – history and appropriate skin testing
Intensity of treatment determined by severity of disease
Immunotherapy
- Usually reserved for seasonal allergies uncontrollable with drugs and not responding to environmental adjustment
- Specific allergen extract is injected subcutaneously in increasing doses to patient tolerance as determined by local reaction
- Patient response should be evaluated each season or year

SURGICAL MEASURES

Septoplasty when deviation significant enough to interfere with benefits of medication.

ACTIVITY

No specific restrictions. Emphasize avoiding activity in areas of allergen exposure.

DIET

No special diet unless concomitant food reactions suspected and evaluated

PATIENT EDUCATION

Printed material available from many sources including: Asthma & Allergy Foundation of America. 1717 Massachusetts Ave., Suite 305, Washington, DC 20036, (800)7-ASTHMA

PREVENTION/AVOIDANCE

Avoidance – most patients with inhalant allergy have problems controlling their symptoms totally with allergen avoidance
Air conditioning and limited outside exposure during season helpful
Instructions as to the best housekeeping tactics and control for dust mites in patients sensitive to this allergen helpful
Exposure to all animal contacts minimized; discourage house pets
Avoid environmental irritants, e.g., smoke and fumes
Air cleaners
Use of allergy control covers, especially on mattresses and pillows

POSSIBLE COMPLICATIONS

Secondary infection
Otitis media
Sinusitis
Epistaxis
Nasopharyngeal lymphoid hyperplasia
Decreased pulmonary function
Continue to suspect effects of medications
Facial changes (see Signs and Symptoms)

EXPECTED COURSE AND PROGNOSIS

Maximal, beneficially acceptable control of symptoms should be the goal
Treatment tailored to each individual case
Immune system changes over time often associated with lessening of symptoms of allergic rhinitis. Therefore, early, adequate control is important

ASSOCIATED CONDITIONS

Other IgE mediated conditions, e.g., asthma and atopic dermatitis

AGE-RELATED FACTORS

Pediatric:

Consider allergy as principal cause of persistent rhinitis
Family understanding and involvement important
Environmental control requires a cooperative effort and may include carpet and drape removal, removal of house plants, pet control, etc.

Geriatric:

Increased medication side effects
Number and specific types of allergens causing symptoms may change
Symptoms may decrease by 4th-5th decade (not a hard rule)

Others: N/A

PREGNANCY

Physiological changes of pregnancy may aggravate all types of rhinitis including allergic, vasomotor, nonallergic rhinitis with eosinophilia and chronic irritable airways

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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