Overview and Risk Factors
Allergic rhinitis is very common, affecting at least 60 million persons in the United States. Allergens cause release of chemical mediators from mast cells in the nasal mucosa. In turn, these mediators cause rhinorrhea; sinus congestion; sinus pressure (especially when leaning forward); itching that may include the eyes, palate, and nose; and sneezing. Cough results from postnasal drip, and sleep disturbance may contribute to fatigue.
Sinusitis, also known as rhinosinusitis, is an inflammatory process of the paranasal sinuses. The most common causes are viral upper airway infections and allergies. Acute bacterial rhinosinusitis is a secondary event occurring in approximately 2% of cases of viral infection.
Possible risk factors for allergic rhinitis and sinusitis include:1,2
- History of atopy in patient or family.
- Male gender.
- First-born child.
- Birth during a pollen season.
- Early introduction of infant formula and food.
- Early antibiotic use.
- Maternal smoking in first year of life.
- Exposure to indoor allergens (dust mites, animal dander, mold).
- In patients less than 6 years of age, serum IgE of 100 IU/mL or greater.
- Allergic rhinitis.
- Nasogastric intubation.
- Dental infection.
- Cystic fibrosis or other ciliary abnormalities.
- Chemical irritation.
- Obstruction due to tumor, granuloma, or foreign body.
The diagnosis of allergic rhinitis is based on consistent findings in the history and physical examination, and may be confirmed by finding an allergen-induced IgE response during skin testing. Allergic rhinitis can be intermittent (seasonal) or persistent (perennial) and may be described as mild, moderate, or severe, to the extent that it interferes with sleep or daily activities.
Pale or bluish nasal mucosa, edematous turbinates with or without drainage, and "cobblestoning" of the oropharynx may be visible on examination. Fiberoptic rhinoscopy can allow visualization of polyps, septal deviation, foreign bodies, and tumors.
A transverse nasal crease, subcutaneous venodilation under the eyes, and mouth breathing may be signs of allergic rhinitis. Young children may make a clicking sound while rubbing their soft palates with their tongues.
Immediate hypersensitivity skin testing may help establish the diagnosis or the possible role of occupational factors. When the condition is refractory to treatment, such testing may be useful in planning immunotherapy. Negative skin tests do not preclude empiric use of nasal corticosteroids in patients with a high probability of disease based on history and physical examination. However, response to antihistamines and anti-inflammatory medications is not diagnostic of allergic rhinitis; nonallergic rhinitis commonly responds to these medications.
Other tests such as blood eosinophils, serum IgE, and the radioallergosorbent test (RAST) are used in selected situations to assist in diagnosis and treatment planning.
Along with possible symptoms of rhinitis, sinusitis may include purulent nasal discharge, postnasal drip, cough, headache, and teeth or facial pain at sinus sites. Allergic rhinitis may predispose the patient to acute bacterial sinusitis, which may become chronic. Chronic sinusitis may be asymptomatic, but may also affect the sense of smell (anosmia), cause halitosis, and exacerbate asthma. With both acute and chronic rhinosinusitis, mucosal inflammation of the nasal and paranasal sinus cavities is the underlying issue.
In cases of complicated acute, refractory (chronic), or recurrent sinusitis, a sinus CT scan may help determine the presence of an anatomic sinus defect or abscess, or define the extent of mucosal disease.
Avoidance of inciting factors is the most helpful treatment. The following measures are also helpful:
- Nasal irrigation with hypertonic saline solution may improve symptoms.
- Among pharmaceutical treatments, intranasal steroids are first-line agents and may also improve asthma symptoms. They will not help allergic conjunctivitis, for which ophthalmic antihistaminic drops should be used.
- Skin testing focused immunotherapy injections may significantly improve symptoms and quality of life. Beta-blocker therapy is an absolute contraindication to immunotherapy. Immunotherapy injections may help prevent asthma onset in children.
- Cromolyn is generally less effective than nasal steroids, but it can improve symptoms by inhibiting mast cell mediator release.
- Leukotriene receptor antagonists may be used in combination with other medications and are similar in efficacy to loratadine, a second-generation antihistamine.3
- Antihistamines, either oral or intranasal, will improve allergic rhinitis symptoms and are most effective when taken prior to allergen exposure, Adequate treatment with intranasal steroids should preclude the need for antihistamines and decongestants. Second-generation antihistamines have fewer unpleasant side effects.
- NSAIDs improve systemic sequelae, such as cough.
- Nasal decongestant sprays should not be used due to tachyphylaxis, unless on a temporary basis for a few days, or prior to elevation gain (eg, mountains, airplanes).
- Oral decongestants such as pseudoephedrine do not cause tachyphylaxis, which nasal decongestant sprays often do.
- Ipratroprium bromide may be helpful when profuse rhinorrhea occurs.
- Nasal irrigation with hypertonic saline solution may improve symptoms.
- In presumed cases of acute bacterial sinusitis, antibiotics are not always necessary for initial therapy.
- Amoxicillin, amoxicillin-clavulanate, telithromycin, and cephalosporins are reasonable initial options.
- Chronic bacterial sinusitis may require a prolonged course of antibiotics (3-6 weeks).
- Recurrent/chronic disease may necessitate intranasal steroids and a repeat antibiotic course, radiologic imaging, and specialty referral.
- Nasal steroids are the most effective and safest method to control sinonasal inflammation in patients with chronic rhinosinusitis.
- Symptomatic treatment with antihistamines, decongestants, and nonsteroidal anti-inflammatory drugs (NSAIDs) for systemic sequelae, such as cough, congestion, and fatigue, may be helpful.
Nutritional factors may help prevent allergies. Specifically, longer duration of breast-feeding and avoidance of early introduction of potentially allergenic foods appears to reduce the likelihood that infants will develop allergies. In an Italian study, new mothers were advised to breast-feed their infants and to avoid introducing commonly allergic foods (whole cow's milk, eggs, fish, nuts, and cocoa) during the first year of life. Mothers who did breast-feed were also asked to limit dairy products and avoid eggs in their own diets, as well as to avoid exposure to other sources of allergens (smoking, day care attendance prior to age 2) as much as possible. These interventions greatly reduced allergic symptoms, including allergic rhinitis.4
Among individuals with allergic rhinitis, dietary fatty acids and antioxidants can influence the production of allergic mediators, including histamine and leukotrienes, and may thereby play a role in the treatment (and possibly the prophylaxis) of allergic rhinitis and sinusitis.
Some evidence suggests that children who eat less saturated fat and cholesterol and more omega-3 fats have less risk of developing rhinitis. Consumption of butter by children5 and of liver by adolescents6 has been associated with greater frequency of allergic rhinitis. In contrast, use of an omega-3 fatty acid supplement, paired with a multiple vitamin-mineral formula containing selenium, was shown to decrease the number of episodes of sinus symptoms and acute sinusitis in children.7
Limited evidence also suggests that blood levels of vitamins C and E are lower in children with chronic sinusitis than in controls.8 The intake of citrus fruit or kiwi fruit, both high in vitamin C, has been associated with lower frequency of rhinitis in children.9 Vitamin E has immunologic effects that might improve rhinitis symptoms, including suppression of neutrophil migration and inhibition of immunoglobulin E (IgE) production.5 Vitamin E intake from foods was protective against hay fever in an adult population.10 Patients with hay fever taking vitamin E supplements during pollen season experienced lower nasal symptom scores than those of placebo takers.11 Additional studies are needed to determine if food or supplemental sources of ascorbic acid and vitamin E benefit sufferers of allergic rhinitis.
A botanical treatment called butterbur (Petasites hybridus) significantly reduces both histamine and leukotriene production in sufferers of allergic rhinitis.12 Benefits have been shown to be similar to those of a prescription antihistamine (cetirizine), without causing cetirizine's sedative side effects.13,14
What to Tell the Family
Allergic rhinitis and sinusitis are common yet treatable illnesses. Dietary adjustments may play a role in prevention and, to some extent, in treatment-- and they have no problematic side effects. Women who plan to have children should be encouraged to breast-feed (and withhold any dairy products for the at least the first 6 months of life) and not smoke to decrease the risk of allergic rhinitis and therefore sinusitis in their children. Families should adopt the same changes as the patient to improve their own health and encourage patient compliance.
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3. Meltzer EO, Malmstrom K, Lu S, et al. Concomitant montelukast and loratadine as treatment for seasonal allergic rhinitis: a randomized, placebo-controlled clinical trial. J Allergy Clin Immunol. 2000;105:917-922.
4. Marini A, Agosti M, Motta G, Mosca F. Effects of a dietary and environmental prevention program on the incidence of allergic symptoms in high atopic risk infants: three years' follow-up. Acta Paediatr Suppl. 1996;414:1-21.
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7. Linday LA, Dolitsky JN, Shindledecker RD. Nutritional supplements as adjunctive therapy for children with chronic/recurrent sinusitis: pilot research.
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9. Forastiere F, Pistelli R, Sestini P, et al. Consumption of fresh fruit rich in vitamin C and wheezing symptoms in children. SIDRIA Collaborative Group, Italy (Italian Studies on Respiratory Disorders in Children and the Environment). Thorax. 2000;55:283-288.
10. Nagel G, Nieters A, Becker N, Linseisen J. The influence of the dietary intake of fatty acids and antioxidants on hay fever in adults. Allergy. 2003;58:1277-1284.
11. Shahar E, Hassoun G, Pollack S. Effect of vitamin E supplementation on the regular treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2004;92:654-658.
12. Thomet OA, Simon HU. Petasins in the treatment of allergic diseases: results of preclinical and clinical studies. Int Arch Allergy Immunol. 2002;129:108-112.
13. Schapowal A, and the Petasites Study Group. Randomized controlled trial of butterbur and cetirizine for treating seasonal allergic rhinitis. BMJ. 2002;324:144-146.
14. Schapowal A, and the Petasites Study Group. Treating intermittent allergic rhinitis: a prospective, randomized, placebo and antihistamine-controlled study of Butterbur extract Z 339. Phytotherapy Research.2005;19:530-537.