Rhinitis is the inflammation of the nasal mucosa, which presents with anterior and/or posterior nasal discharge, sneezing, nasal obstruction and itching of the nose, lasting more than 1 hour for one or more consecutive days.

Rhinitis is a condition that has a negative impact on the patients' quality of life, affecting their daily life and their productivity at work.

Causative factors

A number of factors, such as allergens, viruses, microbes, irritants, hormonal changes, medications, and more, may lead to the onset of rhinitis, and often more than one cause coexists.

This has led to the formulation of many different ways of classifying rhinitis, with classification based on aetiology being the most accepted.

Classification of rhinitis based on their etiology:
  • Allergic rhinitis
    • Continuous
    • Intermittent
  • Infectious rhinitis
    • Viral
    • Bacterial
  • Occupational rhinitis
  • Medicinal rhinitis
  • Hormonal rhinitis
  • Other causes
    • NARES – Non-allergic eosinophilic rhinitis
    • Irritating factors
    • Food source
    • Gerontology
    • Associated with emotions
    • Atrophic
  • Idiopathic rhinitis

Allergic rhinitis is the most common type of non-infectious rhinitis, with a very high impact on global health, as it is reported that the morbidity reaches 10-20% of the world's population.

Allergic rhinitis – Symptoms and clinical picture

Allergic rhinitis is the inflammation of the nasal mucosa, due to an IgE hypersensitivity reaction, after exposure to allergens.

The clinical picture of the patient with allergic rhinitis includes clear rhinorrhea, with pale and / or purple, edematous nasal mucosa, nasal obstruction, sneezing and itching of the nose. Lacrimation is often present, with swelling of the conjunctiva, itching of the eyes and pigmentation of the lower eyelids (allergic shiner). The patient may feel a sensation of a foreign body in the upper respiratory tract, without a clear cause being found during the endoscopic examination (foreign body, pus, tumor, etc.). The patient's clinical picture may include the transverse crease on the dorsum of the nose (nasal bow), even from childhood, while more rarely the crease of the lower eyelid (Dennie-Morgan line).

Patients with allergic rhinitis also have a number of co-morbidities, mainly from the upper respiratory system and secondarily from other systems. More specifically, patients with allergic rhinitis may come to the ENT clinic with symptoms of chronic rhinosinusitis (CRS), with/or without nasal polyps, recurrent infections of the upper respiratory system, a feeling of fullness in the ears, with or without dysfunction of the Eustachian tubes, serous otitis media of the mucous type, laryngitis, hypertrophy of adenoids, symptoms of conjunctivitis, asthma, food allergies, skin disease (of an atopic nature) and severe sleep disorders.

αλλεργική ρινίτιδα
Pigmentation of the lower eyelids (allergic shiner)
Dennie-Morgan line

Allergic Rhinitis – Diagnosis

The diagnosis of allergic rhinitis is based on the correlation of the patient's history and clinical picture with the results of the diagnostic tests to which he is subjected. It is very important to emphasize that positive diagnostic tests, without a corresponding clinical picture or history, do not establish the diagnosis of allergic rhinitis. Various studies have shown a percentage of up to 45% patients with positive tests for allergic rhinitis, but with a picture of asymptomatic, for allergic rhinitis, patient.

Diagnostic access to allergic rhinitis
  • Medical history

Patients with suspected allergic rhinitis should undergo a thorough medical history. Data such as professional activity and activities in his free time are important for the approach to the disease, as data relating to the patient's exposure to environmental factors (temperature, humidity, etc.) are recorded and data are identified that may act as allergens. The symptoms (nasal obstruction, runny nose, itching, sneezing), their frequency and intensity (intermittent or persistent, mild, moderate or severe) are also recorded.
It is important to record the previous treatments received by the patient, the degree of compliance and response to the medication, as well as the possible side effects experienced.

< 4 days per week
< 4 weeks
4 days per week
> 4 weeks
* Normal sleep
* No disruption of daily activities, recreational sports
* Normal participation in work, school
* Non-annoying symptoms
Moderate \ Severe
At least one of:
* Sleep disorder
* Disruption of daily activities, sports, recreation
* Impaired participation in work, school
* Annoying symptoms
Differentiation of allergic rhinitis based on duration and severity of symptoms according to ARIA guidelines
  • Otorhinolaryngological examination

The otorhinolaryngological examination begins with the assessment of the patient's face, looking for swelling of soft tissues (eyelids, lips, etc.), as well as characteristic signs of the skin or scalp (allergic greeting crease on the bridge of the nose, 'black circles' on the eyelids, signs of atopic dermatitis, rashes, skin and mucous membrane irritations, etc.). During anterior rhinoscopy, the presence of edematous and fluid mucosa is observed, with
purplish hue and hypertrophy of the lower sinuses. Importance is also given to the character of the nasal secretions (clear, colored, etc.), to the presence or absence of scurfs of the nasal mucosa or additional tumors (nasal polyps).

  • Skin tests

Skin tests are the chronologically oldest method (1865, Charles Blackley) for the documentation of IgE immediate hypersensitivity reaction. They are an easy, rapid, low-cost and highly sensitive test for the diagnosis of allergic diseases. There are various skin tests, such as nugget tests (which are the most widespread), patch tests, intraepidermal tests, etc. The basic condition for their correct performance is the existence of high-quality allergens suitable for the specific geographical area.

I. Skin prick tests (SPTs): During SPT's, drops of special allergen extracts are placed on the back or front surface of the patient's forearm. Between each allergen there is a distance of 2-3 cm. After that, there is a nygmos with a special scribbler. After a period of 15-20 minutes, the nugget point is observed: if a bump has appeared, with a diameter greater than / equal to 3mm, with local redness and itching, then the test is considered positive. A positive test means that the patient is sensitized to the specific allergen, but not necessarily allergic. As allergens, extracts are taken in diluted form from pollens, mites, fungi, epithelia of pets or domestic animals, pharmaceutical preparations or even hymenoptera venom. In the diagnosis of food allergies, it is possible to use as allergens even pure foods (milk, egg, nuts, grains, legumes, seafood), with the method of double prick (prick to prick test).

II. Intradermal Tests (ID): In these skin tests, a small amount of allergen is administered under the surface layer of the skin, until an 8-10mm papule appears (corresponding to the Mantoux test). The ID tests are a continuation of the SPT's
and concern hymenoptera allergies and drug allergies.

III. Atopy Patch Tests (APT): To perform these skin tests, small paper discs, impregnated with various allergens, are used. The discs are placed on the patient's back and remain in contact with the skin for 48 h. The results are read in 48-
72h (up to 96h). APT's have clinical application in the diagnosis of allergic contact dermatitis and gastrointestinal diseases such as eosinophilic esophagitis and allergic proctocolitis.

  • In Vitro allergy testing

In vitro testing for allergies is performed with RAST techniques and CRDs techniques. Total IgE antibody titers (quantification of IgE) in the patient's blood serum are calculated by laboratory techniques, called RAST (Radio Allergo Sorbent Test). The methods used are Phadebas RAST, Cellulose RAST, Agarose RAST, Matrix, MAST, FAST, AlaSTAT, Immulite 2000, UNICAP System, ImmunoCAP and Phadia (3rd generation). These techniques pose no risk to the patient and are particularly useful in cases of skin allergies. Their specificity ranges between 85-95%, while their sensitivity is lower than SPT's (90%). It is possible for IgE to be positive in a patient with negative SPT's, so the results should be interpreted based on the patient's history and clinical picture. Molecular diagnostic techniques (CRDs) define allergic sensitization at the molecular level, because specific IgE (s-IgE or specific IgE) is measured against purified natural or recombinant allergens. With this method, the real sensitization of the organism is distinguished, against the cross-sensitivity, thus improving the diagnostic accuracy and the specificity of the technique. Molecular diagnostic techniques (CRDs) are divided into two categories: singleplex, where a single allergen is evaluated, and multiplex, where multiple allergens are evaluated simultaneously. With the ISAC Test (Immuno Solid-phase Allergen Chip), which is one of the most established multiplex CRDs techniques, it is possible to measure s-IgE in 112 allergens (protein molecules) found in 50 different animal and plant sources. It is important to mention that in various studies on the Greek population, it was found that 68.5% of the patients had seasonal allergens exclusively and 50% was sensitive to the 3 main seasonal allergens of Greece (partridge, grass and olive). In the ECRHS (European Community Respiratory Health Survey) large variations are reported even within the same country. In the whole population, in fact, sensitization to mites was 21% and approximately the same to grasses (19%), while among the monosensitive the results were as follows: sensitization to mites 28%, to grasses 23% and to Parietaria 4%.

Due to the high cost of these techniques, their use should concern limited allergens, patients who are being treated for an allergy, and patients who do not wish to undergo or do not have access to skin tests.

  • Rhino Challenge Test

For the diagnosis of allergic rhinitis, in cases where the medical history and the results of clinical laboratory control are conflicting, nasal provocation tests are appropriate. Initially they were used to diagnose occupational rhinitis, however in recent years it has become an important diagnostic tool for allergic rhinitis. To carry out these tests, intranasal aeroallergens, mainly pollens, mites and animal epithelia, are administered in gradually increasing concentrations and the symptoms are evaluated (runny nose, nasal obstruction, wheezing, itching, etc.). These symptoms confirm the allergic background, help identify the responsible allergen, and capture the clinical significance of an allergen in a patient who may have multiple sensitivities. With nasal provocation tests, it is possible to assess a patient's response to treatment in both the early and late phases of allergic rhinitis. Clinical application of challenge tests is presented in pharmacology, where topical formulations are evaluated in vivo. Nasal provocation tests, however, have a limitation in terms of the frequency with which they can be applied, in relation to RASTs and SPTs, they entail a degree of ambiguity in the interpretation of the results (subjective assessment by the patient and the attending physician), but and pose risks to the patient, since they are exposed directly to allergens, where they may cause a widespread allergic reaction.

Allergic rhinitis – Treatment

  1. Avoiding allergens
  2. Medication
    • Intranasal steroids
    • Intranasal antihistamines
    • Intranasal decongestants
    • Colors
    • Systemic steroids
    • Per os antihistamines
    • Per os decongestants
    • Antileukotrienes
  3. Immunotherapy
  4. Conservative non-pharmacological treatment
  5. Alternative treatment
  6. Surgical treatment
    • Plastic reconstruction of scoliosis of the nasal septum
    • Shrinkage of the lower sinuses
    • Functional endoscopic surgery of the nose and paranasal sinuses – FESS
    • Botox
    • Cross-section of the sciatic nerve

Photo source https://en.wikipedia.org/wiki/Allergic_shiner

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