Allergic Rhinitis

Overview

It is an Ig. E Mediated immunologic response of nasal mucosa to airborne allergens and is characterized by watery nasal discharge, nasal obstruction, sneezing also itching in the nose. This may also be associated with symptoms of itching in the eyes, palate and pharynx.

Symptoms onset is often within minutes following allergen exposure and can affect sleep, and the ability to work or study. Some people may develop symptoms only during specific time of the year, often as a result of pollen exposure. Many people with allergic also have asthma, allergic conjunctivitis, or atopic dermatitis [1].

Causes

[1] Inhalant allergens

(a) Seasonal allergens for example;

• pollens from trees,
• grasses

(b) Perennial allergens

They are present throughout the year regardless of the season, For example

• Mold
• Dust mites
• Cockroaches
• Dander from animals

Dust includes dust mite, insect parts, fibres and animal dander. Dust Mites live on skin scales also other debris and are found in the beddings, mattresses, pillows, carpets also upholstery.

[2] Genetic Predisposition

It plays an important part.

Chances of children developing allergy are 20 and 47%, respectively, if one or both parents suffer from allergic diathesis [2].

Types

Two clinical types have been recognized:

1. Firstly, Seasonal:

Symptoms either appear in or around particular season when the pollens of a particular plant, to which the patient is sensitive, are present on the air.

2. Secondly, Perennial:

Symptoms are present throughout the year.

Risk Factors for Allergic Rhinitis

• The presence of other allergic diseases such as asthma, eczema
• Parental rhinitis
• Allergic sensitization to common household aeroallergens
• higher-weight person
• Elevated exhaled Nitric oxide
• High total serum IgE
• Exposure to parental smoking
• Exposure to pets
• Genetic predisposition
• Exposure to fossil fuel also traffic related pollutants
• Increased dampness also poor ventilation from tightly insulated modern homes (increases sensitization and allergy to molds)
• Early introduction of infants to formula/food[4]

Pathophysiology

Inhaled allergens produce specific Ig. E antibody in the genetically Predisposed individuals. This antibody becomes fixed to the blood basophils or tissue mast cells by its Fc end

On subsequent exposure, antigen combines with Ig. E antibody at its Fab end. This reaction produces degranulation of the mast cells with release of several chemical mediators, some of which already exist in the preformed state while others are synthesized afresh.

These mediators are responsible for symptomatology of allergic disease.

Depending on the tissues involved, there may be vasodilation, mucosal oedema, infiltration with eosinophils, excessive secretion from nasal glands or smooth muscle contraction. A “priming affect” has also been described, i.e., mucosa earlier sensitized to an allergen will react to smaller doses of subsequent specific allergen. It also gets “primed” to other nonspecific antigens to which patient was not exposed. Nonspecific Nasal hyper-reactivity is seen in patients of allergic rhinitis.

There is increased nasal response to normal stimuli resulting in sneezing, rhinorrhoea also nasal congestion [2].

Clinically allergic response occurs in two phases i.e.:

1.Acute or early phase

It occurs immediately within 5–30 min, after exposure to the specific allergen and consists of sneezing, rhinorrhoea nasal blockage and/or bronchospasm. It is due to release of vasoactive amines like histamine.

 2.Late or delayed phase

It occurs 2–8 h after exposure to allergen without additional exposure. It is due to infiltration of inflammatory cells—eosinophils, neutrophils, basophil, monocytes and CD4 + T cells at the site of antigen deposition causing swelling, congestion and thick secretion.

In the event of repeated or continuous exposure to allergen, acute phase symptomatology overlaps the late phase [2].

Sign and Symptoms:

Symptoms 

• There is no age or sex predilection.
• It may start in infants as young as 6 months or older people.
• Usually the onset is at 12–16 years of age.
• The cardinal symptoms of seasonal nasal allergy include paroxysmal sneezing, 10–20 sneezes at a time, nasal obstruction, watery nasal discharge and itching in the nose. Itching May also involve eyes, palate or pharynx. Some may get bronchospasm. The duration and severity of symptoms may Vary with the season.
• Symptoms of perennial allergy are not so severe as that of the seasonal type. They include frequent colds, persistently stuffy nose, loss of sense of smell due to mucosal oedema, postnasal drip, chronic cough and hearing impairment due to eustachian tube blockage or fluid in the middle ear.

Signs

Signs of allergy may be seen in the nose, eyes, ears, pharynx or larynx.

Nasal signs i.e.

include transverse nasal crease—a black line across the middle of dorsum of nose due to constant upward rubbing of nose simulating a salute (allergic salute), pale and oedematous nasal mucosa which may appear bluish. Turbinate’s are swollen. Thin, watery or mucoid discharge is usually present [2].

Ocular signs i.e.

include oedema of lids, congestion and cobble- stone appearance of the conjunctiva, and dark circles under the eyes (allergic shiners).

Otologic signs i.e.

include retracted tympanic membrane or serous otitis media as a result of eustachian tube blockage.

Pharyngeal signs i.e.

include granular pharyngitis due to hyperplasia of submucosal lymphoid tissue. A child with perennial allergic rhinitis may show all the features of prolonged mouth breathing as seen in adenoid hyperplasia.

Laryngeal signs i.e.

include hoarseness and oedema of the vocal cords.[2]

Clinical Examination

The examination of patients with rhinitis should include an examination of the nose, and assessment for possible comorbidities and complications. The physical examination of a patient with rhinitis may reveal the following i.e.:

General Appearance

• Rhinorrhea may be seen
• Mouth breathing from nasal congestion
• Sniffing
• Allergic shiners: Dark eye shadows beneath the lower eye lid due to blood/fluid accumulation in the infraorbital groove as a result of congestion of the nose/sinuses. It is commonly seen in childhood allergic rhinitis, and the degree of darkness is associated with the chronicity and severity of disease. It can also be seen in nonallergic rhinitis.
• Dennie–Morgan lines: These are wrinkles/ extra skin fold underneath the lower eyelids. It is seen in children with allergic diseases such as allergic rhinitis.
• Allergic salute- A habitual gesture of rubbing the nose upward because of nasal discomfort and pruritus. It sometimes produces a persistent horizontal crease across the nose.

Ocular findings:

Commonly seen in patients with allergic rhinitis. Some of the ocular findings include i.e.:

• Bilateral conjunctival injection, papillae and cobblestones.
• Corneal involvement in severe cases (atopic and vernal keratoconjunctivitis).
• Frequent rubbing of the eyes, irritability, lacrimation, mucus discharge.
• Blepharospasm
• Periorbital edema

Nasal findings:

Examination of the nasal cavity with a speculum or otoscope may reveal the following i.e.:

• Swollen/edematous turbinates
• Pale, bluish or erythematous mucosa. The mucosa is often pale/bluish in allergic rhinitis. 

Ear findings:

Otoscopic examination of the ears may reveal signs suggestive of associated co-morbidities such as:

• Otitis media with effusion- common in patients with allergic rhinitis.
• Acute otitis media

Face

• Facial tenderness/discomfort on palpation of the sinuses. This often occurs when the inflammation extends into the sinuses (rhinosinusitis), and it can be as a result of infection or allergy
• Abnormal facial development such as elongated facies may be seen, especially in chronic mouth breathers.

Mouth and Throat

• Coexisting conditions like hypertrophied adenoids may be seen.
• Dental malocclusion frequently occurs in children who are chronic mouth breathers.
• High arch in the palate
• Cobblestoning of the oropharynx
• Posterior drainage of nasal secretions

Skin

• Eczema may be seen in patients with allergic rhinitis if there is coexisting atopic dermatitis.

Chest

• A thorough chest examination is essential, as it may reveal abnormalities suggestive of other pathological conditions or co-morbidities such as respiratory tract infections, asthma.[5]

Diagnosis

[1] Allergic skin test

[2] CBC shows eosinophilia

Differential Diagnosis of Allergic Rhinits

1. Deviated nasal septum/septal wall anomalies
2. Adenoidal hypertrophy
3. Nasal tumors (benign and malignant)
4. Foreign bodies- Unilateral, mucopurulent rhinorrhea in children could be as a result of insertion of foreign objects into the nostril.
5. Trauma
6. Anatomical variants in the ostiomeatal complex
7. Choanal atresia
8. Cleft palate
9. Pharyngeal reflux (laryngopharyngo-nasal reflux)
10. Metabolic conditions such as acromegaly

Investigation of Allergic Rhinitis

To measure your antibodies to specific allergens, your provider may take a blood sample also send it to a lab for testing. Additionally, This blood test is called an immunoglobulin E (IgE) test.

It can detect all types of allergies, including food allergies.

Your provider may recommend a skin prick test to determine what allergens are causing your symptoms.

Skin prick test

This common test is painless and accurate, though it may be a little uncomfortable. Your provider places a small sample of different allergens on your skin (usually on your forearm or back) also scratches or pricks the skin with a needle. Scratching the skin allows the allergen to get under the surface.

If you’re allergic to the allergen, the area will become red, itchy also irritated in 15 to 30 minutes. You may develop raised, hive-like welts called wheals that show an allergic reaction. A skin prick test is a safe, effective way to determine which allergens are causing your symptoms.[6]

Treatment of Allergic Rhinitis:

 it’s can be divided into:

1. Avoidance of allergen i.e.

This is most successful if the antigen involved is single. Moreover, Removal of a pet from the house, encasing the pillow or mattress with plastic sheet, change of place of work or sometimes change of job may require.

A particular food article to which the patient is found allergic can eliminate from the diet.

2. Drugs:

(a) Antihistaminic i.e.

They control rhinorrhoea, sneezing and nasal itch. All antihistaminic have the side effect of drowsiness; some more than the other. The dose and type of the antihistaminic has to be individualized. If one antihistaminic is not effective, another may try from a different class [2]

(b) Sympathomimetic drugs (oral or topical) i.e.

Alpha-adrenergic drugs constrict blood vessels and reduce nasal congestion and oedema. They also cause central nervous system stimulation and are often giving in combination with antihistaminic to counteract drowsiness. Pseudoephedrine and phenylephrine are often combining with antihistaminics for oral administration. Additionally, Topical use of sympathomimetic drugs causes nasal decongestion.

Phenylephrine, oxymetazoline and xylometazoline Are often used to relieve nasal obstruction, but are notorious to cause severe rebound congestion. Patient Resorts to using more and more of them to relieve nasal obstruction. This vicious cycle leads to rhinitis medicamentosa.

(c)Corticosteroids i.e.

Oral corticosteroids are very effective in controlling the symptoms of allergic rhinitis but their use should limit to acute episodes which have not controlled by other measures.

3. Immunotherapy i.e.

Immunotherapy or hyposensitization is used when drug treatment fails to control symptoms or produces intolerable side effects [2].

Prevention of Allergic Rhinitis

Allergic rhinitis cannot be prevented. You can help your symptoms especially by avoiding the things that cause your symptoms.

• Keep windows closed. This is especially important during high-pollen seasons.
• Wash your hands after petting animals.
• Use dust- also mite-proof bedding and mattress covers.
• Wear glasses outside to protect your eyes.
• Shower before bed to wash off allergens from hair and skin.

You can also avoid things that can make your symptoms worse, such as:

• Aerosol sprays
• Air pollution
• Cold temperatures
• Humidity
• Irritating fumes
• Tobacco smoke
• Wind
• Wood smoke[5]

Homeopathic management of Allergic Rhinitis:

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Allergic Rhinitis:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

1. Allium Cepa:

• Action: Primarily targets acrid nasal discharge that irritates the nostrils, accompanied by bland (non-irritating) eye discharge. Think of the symptoms you get from cutting an onion.
• Symptoms: Watery eyes, sneezing, burning sensation in the nose, and a runny nose that worsens in a warm room and improves in open air.

2. Arsenicum album:

• Action: Suitable for rhinitis with thin, watery, and burning nasal discharge, often accompanied by sneezing and restlessness.
• Symptoms: Burning and itching in the nose, sneezing, watery discharge, and a general feeling of chilliness. Symptoms often worsen at midnight or with changes in temperature.

3. Natrum muriaticum:

• Action: Addresses allergic rhinitis with excessive sneezing, often as the initial symptom.
• Symptoms: Dry mucous membranes, loss of taste and smell, watery nasal discharge, and a craving for salt.

4. Euphrasia:

• Action: Focuses on profuse, acrid tears with bland nasal discharge.
• Symptoms: Burning and redness of the eyes, sensitivity to light, and a constant need to wipe the eyes.

5. Pulsatilla:

• Action: Often used for allergic rhinitis with thick, yellow-greenish discharge and a lack of thirst.
• Symptoms: Changeable symptoms, tearful disposition, and a desire for open air. Symptoms often worsen in warm rooms and improve with cold applications.

6. Kali bichromicum:

• Action: Targets cases with thick, stringy, and yellow or greenish nasal discharge.
• Symptoms: Nasal blockage, post-nasal drip, and a loss of smell.

7. Sabadilla:

• Action: Helpful when there’s intense itching in the nose and violent sneezing, often triggered by specific odors.
• Symptoms: Sneezing attacks, watery nasal discharge, and a dry mouth.

8. Wyethia:

• Action: Addresses intense itching in the nose, roof of the mouth, and behind the ears.
• Symptoms: Dryness of the nose and throat, constant need to swallow, and a feeling of a lump in the throat.

Diet and Nutrition:

Try to reduce your exposure to some allergens, such as dust mites, animal dander’s, pollens etc. wash your bedding in very hot water like 130-degree F and dry it hanging in open sunny area or in a hot dryer minimum once in a week

Wear a mask while cleaning your house or gardening which keeps pollen out of your nose and mouth Clean your floors with a damp mop or cloth daily. If you are putting carpet then clean it by vacuum 2 to 3 times in a week.

Other Dietary Measure

Use baking soda, mineral oil, club soda, or vinegar to clean instead of using cleaning solutions. Don’t Let Pets Sleep with You. Their fur and dander (dried skin, hair, and saliva) can cause allergy to your body.

Keep your house plants outside the house in spring season. Because the mold spores that live in the warm and wet dirt of the flower bucket.

Allergy or hay fever develop in a person of hypersensitive immune system. The immune system becomes hypersensitive if you always stay in a constant stress. so, meditation, yoga, pranayama is very much essential to keep you stress free.

Exercise regularly. Exercise produces adrenaline, a natural way to relieve a stuffy nose. Use either an air conditioner or air purifier with a high-efficiency particulate air (HEPA) filter.[3]

Reference

1. https://en.wikipedia.org/wiki/Allergic_rhinitis
2.  Disease of EAR, NOSE, AND THROAT&HEAD AND NECK SURGERY 6^TH EDITIONS BY P.L Dhingra, Shruti Dhingra.
3. https://www.multicarehomeopathy.com/diseases/6-best-homeopathic-medicines-for-allergic-rhinitis-treatment
4. https://www.wikidoc.org/index.php/Rhinitis_risk_factors
5. https://familydoctor.org/condition/allergic-rhinitis/
6. Abbas, A. K., Lichtman, A. H., & Pillai, S. (2020). Cellular and Molecular Immunology (9th ed.). Elsevier.
7. Holgate, S. T., Pawankar, R., Akdis, C. A., & Canonica, G. W. (2015). Middleton’s Allergy: Principles and Practice (8th ed.). Elsevier Saunders.
8. Bachert, C., Akdis, C. A., & Gevaert, P. (2019). Allergic Rhinitis and Chronic Rhinosinusitis: A Practical Guide (2nd ed.). Springer.

9. Galli, S. J., Tsai, M., & Piliponsky, A. M. (2008). The development of allergic inflammation. Nature, 454(7203), 445-454.

10. Bielory, L., & Friedlaender, M. H. (2019). Allergic Diseases: Diagnosis and Management (5th ed.). Little, Brown and Company.
11. Corren, J., Baroody, F. M., & Togias, A. (2018). Allergic Rhinitis and Its Impact on Asthma (ARIA) 2016 Revision. Journal of Allergy and Clinical Immunology, 142(4), 984-991.
12. World Health Organization. (2016). Allergic Rhinitis and its Impact on Asthma (ARIA) Guidelines.
13. Kern, R. C., & Conley, D. B. (2016). Clinical Otolaryngology: Head and Neck Surgery (2nd ed.). Elsevier.
14. Pawankar, R. (2011). Allergic rhinitis and asthma: The united airway disease concept. Asian Pacific Journal of Allergy and Immunology, 29(1), 1-6
15. Bousquet, J., Schünemann, H. J., Zuberbier, T., & Bachert, C. (2012). ARIA guidelines—2012 revision. Allergy, 67(8), 969-1000.
16. Cox, L., Nelson, H., Lockey, R., & Calabria, C. (2011). Allergen immunotherapy: A practice parameter third update. Journal of Allergy and Clinical Immunology, 127(1), S1-S55.