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Allergic rhinitis 

Allergic rhinitis

Allergic rhinitis

Stephen R. Durham

and Hesham Saleh

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date: 28 April 2017

Allergic rhinitis affects more than 20% of the population of Westernized countries and has a significant impact on quality of life and school/work performance.

Aetiology and clinical features—important environmental factors include tree and grass pollens (seasonal allergic rhinitis); house dust mite and domestic pets, most often cats (perennial allergic rhinitis); and a variety of occupational exposures (occupational rhinitis). Many genetic loci confer susceptibility. Immediate symptoms (itching, sneezing, and watery nasal discharge) occur as a consequence of allergen cross-linking adjacent IgE molecules on the surface of mast cells in the nasal mucosa, resulting in the release of histamine and tryptase, and the generation of bradykinin.

Diagnosis and classification—diagnosis is usually straightforward and based on the history, examination and (when indicated) the results of skin prick tests and/or serum allergen-specific IgE levels. Classification is according to the severity and duration of symptoms as defined by ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines, which describe four categories of disease: (1) mild intermittent, (2) moderate/severe intermittent, (3) mild persistent, and (4) moderate/severe persistent. Differential diagnosis and management of more complex cases are helped by flexible or rigid nasal endoscopy and CT of the nose and paranasal sinuses.

Management—allergen avoidance, topical intranasal corticosteroids, and nonsedating oral antihistamines are the mainstay of treatment and are effective and safe. Treatment failure often results from poor compliance or inadequate technique in use of nasal sprays. Allergen injection immunotherapy, which has been shown to induce long-term disease remission, is indicated in patients with severe seasonal allergic rhinitis who fail to respond to usual measures. Rhinitis is often accompanied by significant comorbidities that include conjunctivitis, sinusitis, otitis media, and bronchial asthma: these require separate recognition and treatment.

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