What is Allergic Rhinitis?
Allergic rhinitis (hay fever is another name for it) is a condition where your body’s immune system mistakenly considers normal things, like pollen or pet dander, as danger and overreacts to protect you. This can lead to symptoms like a stuffy nose, a continuously runny nose, sneezing, a dripping feeling at the back of your throat, and itchiness inside your nose. One out of six people are affected by this condition and it may lead to considerable discomfort, reduced productivity, and can increase healthcare costs.
Earlier, it was believed that allergic rhinitis only affected the nasal airway. However, this view has changed; it is now seen as part of a larger allergic reaction affecting the entire body. It is often linked with other allergies like asthma and atopic dermatitis (a type of skin inflammation), suggesting these conditions may have a common root cause.
Allergic rhinitis is categorized as either seasonal (occurs during certain seasons and then disappears) or perennial (persistent throughout the year). Roughly, 20% of cases are seasonal, 40% are perennial, and the rest display a mix of both. Other than the nasal symptoms, people with allergic rhinitis can also experience symptoms like allergy-related eye inflammation, a dry cough, problems with the tubes connecting the ear to the throat (Eustachian tube dysfunction), and long-term sinus inflammation.
Once diagnosed, allergic rhinitis can be managed with various treatments. The initial treatment typically includes nasal sprays that contain glucocorticoids (medicines that reduce inflammation).
What Causes Allergic Rhinitis?
Allergies can cause your body to react in two different ways: right after you’re exposed to what you’re allergic to, and then again a bit later. A common allergy reaction, called allergic rhinitis, is created by your body fighting against something you’ve breathed in that it doesn’t like. This is done by your body using type 2 helper cells and a special type of antibody called immunoglobulin E (IgE). This reaction happens within 5 to 15 minutes of coming into contact with what you’re allergic to and leads to the release of several substances, including histamine, from cells known as mast cells.
Histamine, an important player in allergic reactions, triggers sneezing and also stimulates your mucus glands, which can cause a runny nose. It also causes chemical reactions that can lead to a stuffy nose. Around four to six hours after the first reaction, a group of proteins called cytokines enter the scene, marking the beginning of the late-phase response. These proteins, in particular interleukins (IL)-4 and IL-13, help bring more immune cells into your nasal lining and cause it to swell, making you feel stuffy.
It’s also possible for your body to start reacting more strongly than normal to things that don’t normally cause an allergic reaction, such as tobacco smoke or cold air. This can happen if particular types of cells, called eosinophils, build up in your nasal lining and cause symptoms like sneezing, a runny nose, and an itchy nose.
Some people might be more likely to get allergic rhinitis because of their genes, but we don’t know a lot about this yet. Research shows that there is a higher chance of having allergic rhinitis if you have an identical twin who has it compared to having a fraternal twin with the condition. Some studies also found that specific areas on your third and fourth chromosomes could be related to allergic reactions.
Risk Factors and Frequency for Allergic Rhinitis
Allergic rhinitis, a condition causing symptoms like a stuffy or runny nose, is diagnosed in about 15% of people. However, up to 30% of people experience nasal symptoms that could indicate they have this issue. It often starts between the ages of 10 and 40, and then tends to gradually reduce as people get older. For kids, allergic rhinitis is one of the most common chronic issues they face. Studies show that 14.6% of kids between 13 to 14 years old and 8.5% within the 6 to 7 age range show symptoms of allergic rhinitis. It seems that seasonal allergic rhinitis is more typical in kids, while chronic rhinitis is more frequent in adults.
A study from 2018 showed that 3.6% of adults had missed work, and 36% had a harder time performing at work because of allergic rhinitis. When taking into account the loss of work productivity, the cost impact of allergic rhinitis can be quite high.
- Several risk factors that could increase the chances of developing allergic rhinitis include:
- Having family members with similar issues
- The person’s sex is male
- The presence of allergen-specific substances in the blood
- High levels (greater than 100 IU/mL before age 6) of substance called serum IgE in the blood
- Being in a higher socioeconomic status
- For very young children, introducing foods or formula early or exposure to a lot of cigarette smoke in the first year of life could increase the chance of allergic rhinitis
While it has been suggested that pollution could be linked to the development of allergic rhinitis, no proven significant link has been found. Interestingly, there are a few things that could potentially reduce the risk of developing allergic rhinitis, including early exposure to pets, which could boost immune tolerance, and living on a farm in the first year of life, which is associated with a 40% lower risk. As for breastfeeding, its role in the development of allergic rhinitis remains debated. Nevertheless, it is still encouraged due to its other known benefits.
Signs and Symptoms of Allergic Rhinitis
When evaluating allergic rhinitis (AR), doctors need to get a comprehensive patient history. This will include details about the nature of symptoms, when they happen, how long and how often they occur, any suspected triggers, what makes them better or worse, and any patterns related to seasons. People with seasonal or occasional AR often have symptoms such as sneezing, runny nose, and watery eyes. On the other hand, those with chronic AR usually complain about postnasal drip and constant nasal congestion and blockage. These patients often have a family history of AR or personally have asthma. Intermittent rhinitis patients may identify triggers like pollen, animal hair, certain types of flooring or upholstery, molds, humidity, perfumes, and tobacco smoke.
During a physical exam, doctors may observe mouth breathing, frequent sniffling, throat clearing, a nasal crease above the tip of the nose, and dark circles under the eyes. Nasal crease above the tip is more frequent in children. A nose exam may show swelling of the nasal lining and thin, clear nasal secretions. Often, the nasal lining takes on a bluish color and may appear ‘cobblestoned.’ If possible, doctors will do an internal endoscopic exam of the nose to look for nasal polyps and structural abnormalities. A pneumatic otoscope can help check for eustachian tube dysfunction, which is a common finding in patients with AR. Checking the sinuses may reveal tenderness in patients with chronic symptoms. These patients should also be carefully examined for signs of asthma or skin inflammation, and they should be asked about sensitivity to aspirin.
Testing for Allergic Rhinitis
Allergic rhinitis, also known as hay fever, is mostly diagnosed based on a detailed review of a patient’s health history and a physical exam. Sometimes, doctors may recommend a trial treatment with a nasal steroid spray. If symptoms improve with this treatment, it adds weight to the diagnosis of allergic rhinitis.
Another way to diagnose allergic rhinitis is through allergy testing. This can involve either a blood test to look for specific allergy-causing substances (allergens) or a skin prick test. However, allergy testing is usually done only for patients who don’t respond to initial treatment or who need to identify specific allergens for targeted therapy.
The blood test does not require trained technicians, and patients don’t need to stop taking antihistamines before the test. The skin prick test, which involves a trained professional scratching the skin with a tiny amount of allergen, has quicker results. If patients experience worse symptoms in certain seasons, it is best to test during these times to identify triggers more accurately.
Skin prick testing is slightly more sensitive than blood testing and is typically cheaper. However, it may not be suitable for everyone. Patients with severe asthma, unstable heart disease, pregnancy, or taking certain medications may not be suitable candidates for skin prick testing. Certain medications, like H2-antagonists (used for heartburn relief), tricyclic antidepressants, and the allergy medication omalizumab, can interfere with test results, so it might be necessary to stop taking them before testing.
Images from techniques like X-rays or scans are not routinely used to diagnose hay fever. They are generally used mainly for ruling out other conditions that could be causing your symptoms, such as sinus infections.
Treatment Options for Allergic Rhinitis
To reduce seasonal allergy symptoms, try to avoid triggers like dust mites and pet hair. If you can’t remove a pet, keep it in one room to reduce exposure. Use insulated bedding, wash bed sheets in hot water, and use a vacuum cleaner with a high-efficiency filter. Medical treatments include antihistamines, nasal sprays with steroids, leukotriene receptor antagonists, and immunotherapy. Nasal sprays with steroids are better than antihistamines at reducing inflammation in the nose. First-generation antihistamines can make you sleepy, while second-generation antihistamines are less sedating. Antihistamine nasal sprays with azelastine (Affrin) are fast-acting and more effective than oral antihistamines. Leukotriene receptor antagonists are less effective than nasal sprays with steroids. Oral decongestants and nasal decongestants provide temporary relief but should not be used long-term. Sodium cromoglycate effectively reduces symptoms. Surgical treatment is only for structural issues. Budesonide is safe for pregnant patients. Omalizumab helps with allergic reactions but is expensive. Nasal saline can be used with other treatments.
What else can Allergic Rhinitis be?
When diagnosing Allergic Rhinitis (AR), doctors would consider various other conditions that may exhibit similar symptoms. These other conditions are not necessarily linked to allergies. Special attention should be given to children, especially those below 2 years old, to check for inborn sources of nasal blockage, like choanal atresia and deficiencies in the immune system.
- Vasomotor rhinitis: This is a non-inflammatory type of rhinitis that can be triggered by a change in temperature, smells, or humidity.
- Infectious rhinitis: This is usually caused by viral or bacterial infections, and it’s most common among children.
- Cerebrospinal fluid leak: This condition leads to persistent clear rhinitis that doesn’t respond to treatment.
- Non-allergic rhinitis with eosinophilia syndrome (NARES): This occurs when there’s an influx of a type of white blood cell (eosinophils) in the nose tissues without an allergic reaction.
- Chemical rhinitis: This is caused by exposure to chemicals at work, at home, or during sports and leisure activities.
- Rhinitis of pregnancy and hormonally-induced rhinitis
- Drug-induced rhinitis: This could be caused by medications like NSAIDs, ACE inhibitors, nasal decongestants, and substances like cocaine.
- Autoimmune, granulomatous, and vasculitic rhinitis: Conditions like granulomatosis with polyangiitis and sarcoidosis could cause this.
- Nasal polyposis
- Nasopharyngeal neoplasm
- Sickle cell anemia: In young children showing symptoms of nasal polyposis and well-managed asthma, appropriate tests are necessary to rule out cystic fibrosis.
What to expect with Allergic Rhinitis
It’s commonly believed that the occurrence of allergic rhinitis, or hay fever, is highest in teenagers and then slowly decreases as individuals get older. In a study that tracked people over 23 years, just over half the patients (54.9%) saw their symptoms get better, with almost half (41.6%) of those becoming completely symptom-free. Patients who started experiencing symptoms at a younger age were likely to see more improvement.
The severity of hay fever can change over time and often depends on factors like where you live and what time of year it is. Around half the patients (50%) who received a type of treatment known as grass allergy immunotherapy, which trains the immune system to be less reactive to allergens, reported an improvement in symptoms that continued even three years after they’d stopped the treatment.
Possible Complications When Diagnosed with Allergic Rhinitis
Chronic rhinosinusitis, a nose inflammation, can often complicate allergic rhinitis. This condition, characterized by nasal blockage or immune fluid discharge lasting over three months can result in the formation of nasal polyps. Nasal polyps are the growths that result from prolonged inflammation in the linings of one’s sinuses. Generally non-cancerous and occurring on both sides of the nose, it’s more concerning if a nasal polyp is only found on one side as this could indicate cancer. Around 4% of people have nasal polyps, and it’s more common in men. Treatment mainly involves the use of nasal steroids and rinsing with saline water, however, if these don’t work, surgical removal is considered.
Allergic rhinitis can also affect one’s immune response to allergens in the adenoids, causing them to become enlarged. This condition, known as adenoid hypertrophy, is common in patients with allergic rhinitis. It can result in symptoms like a sense of ear fullness, ear pain, and ear-popping. Around 10 to 40% patients with allergic rhinitis also suffer from asthma, suggesting a correlation between the two conditions, particularly in cases of persistent moderate to severe rhinitis. Allergic rhinitis has been found to independently increase the risk of asthma, more so if diagnosed during infancy. Other associated conditions include otitis media with effusion (fluid build-up in the middle ear), persistent cough, and eosinophilic esophagitis (inflammation in the food pipe), although the links need to be further studied.
For patients who undergo allergen desensitization treatments (allergy shots), there’s a risk of their allergic rhinitis or asthma symptoms worsening. In rare, severe cases, they could even experience anaphylaxis, a severe and potentially life-threatening allergic reaction. Due to this, it’s important for medical staff in these facilities to be trained in managing such reactions. They should have access to emergency medications like epinephrine, as well as airway management equipment, to be used immediately if needed.
Preventing Allergic Rhinitis
People often don’t realize how serious allergic rhinitis, also known as hay fever, can really be, and they may not get the right medical treatment in time. It’s crucial to properly manage this condition, especially because there’s a link between allergic rhinitis and asthma. If you don’t manage your rhinitis well, it’s likely your asthma won’t be managed well either.
Following your doctor’s instructions for treatment is critical for relieving your symptoms. You should receive materials to read about allergic rhinitis and what it means for you. Additionally, learning the correct way to use nasal sprays is very important for your response to the treatment.
Patients need to look downwards and spray just inside their nostril, aiming towards the exterior of both nostril walls. It’s emphasized that after spraying, you should not take a deep breath or sniff very hard.
Talking with your doctor about how to avoid things you know cause your allergies is also necessary, although it may take some time. The knowledge and understanding you gain can go a long way in helping manage your allergic rhinitis.
