Allergic Rhinitis

Allergic rhinitis is an immediate or late reaction to inhaled allergens, such as pollens, molds, dusts and danders. The symptoms of allergic rhinitis may also develop as a result of sensitivity to foods. This reaction is an immunologic response and results from the allergens binding to various antibodies in the body. This binding then leads to a release of various mediators (i.e. histamine, leukotrienes, etc.) that cause the symptoms of allergic rhinitis. Although allergic rhinitis technically refers only to the nasal symptoms that may occur, this condition is often associated with allergic conjunctivitis, pharyngitis, laryngitis, bronchitis, and otitis media. Thus the eyes, throat, voice box, lungs, and middle ears may also be involved.

The symptoms of allergic rhinitis are too numerous to list here, but the majority of patients suffer from one or more of the following: nasal congestion, runny nose, post-nasal drip, sneezing, sinus pressure headaches, frequent sinusitis, watery eyes, sore throat, hoarseness, chronic cough, middle ear pressure, frequent ear infections, or fatigue. There is often a seasonal variation to the patient’s symptoms, but many times the patient may complain of perennial or year-round symptoms. Although most allergy sufferers tend to notice the onset of their symptoms during childhood or adolescence, allergic rhinitis may develop at any age. It is a matter of how long and how often the patient has been exposed to the allergen and the genetic predisposition of the patient. If one parent has allergic rhinitis, a child has a 30-40% chance of developing the condition. If both parents have allergic rhinitis, a child has a 70-80% chance of developing the condition. Moving to a new environment may result in the development of allergies, particularly to Hampton Roads, which is generally regarded as one of the most allergic communities in the United States. Approximately 35% of Hampton Roads residents suffer from allergic rhinitis.

The mainstays of medical therapy for allergic rhinitis include nasal steroid sprays (i.e. Nasonex, Flonase, Nasacort, etc.), antihistamines (i.e. Claritin, Allegra, Zyrtec, etc.), decongestants (i.e. Sudafed, Entex, etc.), mast cell stabilizers (i.e. Nasalcrom), and in severe cases, oral steroids. Many times antibiotics are necessary to treat infections such as sinusitis, bronchitis, or otitis media. Surgical intervention may be necessary if problems such as chronic sinusitis, nasal polyps, or chronic otitis media develop or if concomitant problems such as nasal septal deviation or turbinate enlargement exist. When medical and/or surgical treatments fail to relieve the patient’s symptoms, it may be necessary to undergo allergy testing. This may be followed by avoidance of the allergens (elimination-rotation diet if the allergens are foods), and usually by allergy shots to desensitize the patient to the allergens (neutralize the allergens in the case of foods). This immunotherapy (allergy shots) results in complex changes in the immune system that lead to a decrease in the release of the mediators responsible for allergic rhinitis.

There are many methods of allergy testing available, but the most sensitive and accurate testing method is multiple dilution intradermal skin testing. This is referred to as serial endpoint titration (SET) in the case of inhalant allergens and intracutaneous progressive dilution food testing (IPDFT) in the case of foods. Other recognized testing methods include in vitro testing (RAST), where a tube of blood is sent to a laboratory for testing, and single dilution intradermal skin testing. The main advantage of skin testing over in vitro testing is sensitivity. Skin testing has far fewer false negative results and thus yields better success rates with injection therapy. RAST may be an alternative, however, in certain situations such as small children who won’t tolerate skin testing, severe skin rashes or hives, inability to stop medications that affect the skin response, or a history of a severe allergic reaction. The main advantages of multiple dilution testing over single dilution testing are as follows: the sensitivity is increased (fewer false negatives), a quantitative measure of the patient’s allergies can be obtained (allowing for a higher starting point and a more rapid improvement in symptoms), an ability to advance each allergen independently from its endpoint to its maintenance dose (allowing for greater success rates with injection therapy, because advancement of other allergens is not limited by those already at maintenance).

The majority of patients who received allergy shots for inhalant allergens do so for three to five years, gradually increasing their shots from weekly to monthly. If this regimen of gradual increase in the shot interval is followed, the vast majority of these patients will experience major improvement in their allergy symptoms long after stopping their shots. With all of the possible treatments available for allergic rhinitis (medications, surgery, and immunotherapy), there is little reason for a patient to "suffer" from allergies.