Allergic Rhinitis

Allergic rhinitis used to be called hayfever. But there is no fever and hay is not really a factor in suburban Australia. But this condition causes considerable distress and results in sneezing, itchy, blocked nose, and often the eyes are involved. The good news is that it is treatable, and desensitisation is possible in some cases.

What is it ?

Allergic Rhiniitis is inflammation of the nasal tissue in response to the presence of ‘allergens’. Allergens are tiny proteins that are present in the air and include dust mite, pollens, Cat hair, dog hair and even some foods and drinks. These allergens are caught on the surface of the mucousa and the body allergically reacts to their presence. This involves inflammation, tissue swelling and nasal discharge.

Who gets it ?

This is usually a condition that develops during childhood. Often there is a family history of allergies such as asthma, and the child may have had eczema at some stage. This usually occurs in middle childhood.

What are the symptoms ?

Blocked nose, sneezing, itchy nose (and eyes) and sometimes snoring due to the mouth breathing. Often the inflammation can extend to the sinuses and result in heavy congested feeling, similar to having a constant cold. These symptoms will be worse when exposed to a particular allergen. The most common is dust mite. Usually these children suffer at night, and clear up during the day, especially if they are outside. The typical case is the child who goes to bed, develops a blocked nose during the night, starts snoring and then sneezes during the morning. In southern states such as Melbourne and Adelaide seasonal allergic rhinitis is due to the pollens produced, particularly during Spring. The hot northerlies will often cause symptoms to develop quickly and there is currently an APP available for those in Melbourne. (Melbourne pollen count and forecast)

What will a doctor see ?

The child will appear congested. There maybe a crease across the bridge of the nose which is called the ‘allergic crease’. This comes from the constant rubbing of the nose upwards when itchy which is called the allergic salute. The inside of the nose will have swollen pink tissue that appears to almost block the nasal passages. Sometimes the eyes will be involved aswell, looking red and itchy with dark circles (from the rubbing).

How to tell what the triggers (allergens) are ?

The most important part of any allergy assessment is the history. If it only occurs in certain times of the year it is termed seasonal and certain pollens can be the culprit. for those who suffer constantly indoor allergens such as dust mite or animal dander are usually factors. Sometime it maybe a food or drink. In such cases there will be a definite deterioration within a short time after the child is exposed. If the symptoms are significant at night it is more likely to be dust mite. Confirming a trigger or allergen can be done by either a blood test or a skin prick test by an allergist, immunologist, or doctor trained in allergic conditions.

What can you do about triggers ?

The common pollens and amount of dust mite particularly on the Eastern Seaboard of Australia means avoidance is generally impossible. Controlling dust mite may improve things but do not expect a cure or marked response. See Dust mite

Treatment ?

This involves lessening the inflammation in the mucosa. The inflammation is an abnormal response by the immune system to the inhaled allergens. The aim of treatment is to ‘calm the immune response’. The two most effective treatments are topical nasal steroids and antihistamines. The antihistamines traditionally were given in tablet form but they can now be delivered intranasally.

Oral Antihistamines – these are available over the counter in tablet and liquid form and work quickly. But they are not as effective as the nasal sprays and their effect is short term. They are useful for the young child who has mild symptoms and cannot tolerate the nasal spray.

Topical Nasal Steroids – This has been shown by numerous studies to be the most effective treatment. These sprays will normalise the mucousal response to allergens. These include nasonex, rhinocort, and avamys.

Note head forward, nozzle pointing to inner aspect same side eye.

They are effective when used correctly
They are safe at the prescribed doses
They will take at least a week before significant improvement is noted
Most young children do not cope with these sprays which makes compliance difficult
They are expensive.
When they are ceased the symptoms will return.

Topical Nasal Antihistamines – The advantage of these are they are steroid free. They are not quite as effective as the topical nasal steroids. The ingredient is called azelastine. It is sold in the pharmacy as Azep

Combined Nasal Antihistamines and Steroids – This is relatively new. Studies have shown this combination works faster (claims 30mins) and is more effective then either ingredient alone. In Australia it is called Dymista. It contains the azelastine and fluticasone. It can leave a bitter taste in the mouth, so use a mint afterwards. If the taste is immediate, this means the sniffing was too hard!

It is important to correctly use the topical nasal sprays. Head forward, insert nozzle into nostril and point towards inner corner of eye. Gently sniff whilst injecting the spray.

What are the complications ?

The nasal mucousa can extend into the sinuses and sometimes conservative treatment makes little difference. Usually this occurs in the adolescent or young adult where the sinus and nasal connections are completely clogged. In this case sometimes surgery is needed. This is rarely required in the child

Desensitisation as a cure ?

Apart from moving to an environment where there are no allergens (Antarctic anyone ?) the only other option is desensitisation. This is a growing area in medicine. This method involves exposing cells that regulate the immune system to very small amounts of the offending allergen repeatedly. This will enable to immune system to develop a tolerance. Unfortunately this can take a number of months before any benefit is perceived and the treatment needs to continue for several years which can make it costly. However it works out cheaper than the cost of the medications and is an option for those who are really suffering. More info at sublingual immunotherapy but here is a brief over of types of desensitisation

Sublingual Immunotherapy drops- this involves drops under the tongue on a daily basis. There are a number of allergens including pollens and dust mite which can be given (even at the same time). It often abbreviated to SLIT.
Sublingual Immunotherapy tablet called oralair. This is taken daily and covers a number of grasses including ryegrass, timothy grass, sweet vernal grass, meadow grass/Kentucky Bluegrass and cocksfoot. They do not contain other potential triggers for hay fever like Bermuda grass, plantain or paspalum or birch tree pollen, and currently no Oralair tablets are available that contain dust mite or mould or pet extracts.
Subcutaneous injections – more appropriate for older children and adults, this method is more effective but there is a risk of a serious allergic reaction, so these need to be given in a doctor’s surgery which makes convenience an issue.