Allergic Rhinitis and Rhinosinusitis
Allergic rhinitis is a common chronic disease affecting about 60 million people in the United States. In sensitized individuals, allergens cause release of chemical mediators from mast cells in the nasal mucosa. These mediators may cause rhinorrhea, sinus congestion, sneezing, and eye, palate, and nasal pruritis. In addition, rhinitis may result in postnasal drip, which, in turn, may lead to a cough, sleep disturbance, and fatigue. In allergic individuals, rhinitis is often seasonal and may worsen significantly during the pollen seasons (spring and fall).
Acute rhinosinusitis is a symptomatic inflammatory and infectious process of the paranasal sinuses and nasal cavity that typically lasts less than 4 weeks. The most common cause is viral upper airway infection. Acute rhinosinusitis can be divided into acute viral rhinosinusitis (AVRS) and acute bacterial rhinosinusitis (ABRS). Acute bacterial rhinosinusitis is a secondary event occurring in up to 2% of cases of viral infection.
Rhinosinusitis can also be classified as subacute (lasting 4-12 weeks) or chronic (lasting more than 12 weeks). Common causes of subacute and chronic rhinosinusitis are upper respiratory infections and acute sinusitis that does not resolve.
- History of atopy in patient or family
- Gender. In childhood, the condition is more common in males; the reverse is true in adulthood
- Firstborn child. Having multiple siblings decreases risk
- Birth during spring or summer
- Early introduction of infant formula and food. Breastfeeding for 3 to 6 months appears to be protective
- Exposure to second-hand smoke during childhood
- Maternal smoking during pregnancy
Exposure to cats and dogs before age 5 or growing up on a farm, is associated with a decreased risk of development of allergic rhinitis. This is thought to be due to the “hygiene hypothesis,” which holds that individuals become “desensitized” with early and repeated exposure and, thus, do not mount an allergic reaction when exposed to various allergens.
The role of air pollution as it relates to the development of allergic rhinitis remains somewhat controversial, and there may be a genetic component that increases risk.
- Upper respiratory viral infection, most commonly with rhinovirus, influenza virus, respiratory syncytial virus, coronavirus, and parainfluenza virus
- Bacterial secondary infection, typically with Streptococcus pneumoniae (most common) and Haemophilus influenzae
- Nasogastric intubation
- Maxillary dental infection
- Local trauma
- Cigarette smoking
- Cocaine use
- Cystic fibrosis or other ciliary abnormalities
- Chemical irritation
- Obstruction: nasal septum deviation, tumor, or foreign body
The diagnosis of allergic rhinitis is based on consistent findings in the history and physical examination, including a seasonal or perennial pattern of rhinorrhea, congestion, and pruritis, as well as positive skin tests for sensitivity to aeroallergens.
Pale or bluish nasal mucosa, edematous turbinates with or without drainage, and “cobblestoning” of the oropharynx may be visible on examination. A transverse nasal crease (the “allergic salute”), puffy 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. Rhinoscopy can allow visualization of polyps, septal deviation, foreign bodies, and tumors. The diagnosis may be confirmed by prick skin testing, which consists of placing a series of liquid extracts containing various allergens on a patient’s forearms and gently pricking the skin. A positive response consists of erythema and a wheal ≥ 3 mm in diameter in the designated area after 20 minutes of observation. Negative skin tests usually exclude an “allergic” or IgE-mediated origin, yet they may not reflect a “nonallergic”/irritant or “vasomotor” reaction.
Other tests, such as blood eosinophils, serum IgE, and the radioallergosorbent test to aeroallergens, are not necessary in most clinical situations.
Sinusitis is diagnosed from signs and symptoms which may include purulent nasal discharge, nasal congestion or blockage, persistent cough, headache, sinus pressure (especially when leaning forward), fever, maxillary tooth pain, and facial pain at sinus sites. Although acute and chronic sinusitis may be asymptomatic, they often cause a decreased sense of smell (anosmia) and halitosis (especially in pediatric patients) and may exacerbate asthma due to mucosal inflammation of the nasal and paranasal sinus cavities.
In cases of complicated acute, refractory (chronic), or recurrent sinusitis, a sinus noncontrast CT scan may help to determine the presence of infection, anatomical abnormalities, tumors, and degree of mucosal disease.
Differentiating acute bacterial rhinosinusitis from acute viral rhinosinusitis is typically based on symptom duration and severity. While AVRS symptoms peak around day 2-3 and disappear by day 10-14, symptoms of ABRS persist longer than 10 days and tend to be more severe.
Avoidance of inciting factors is the most effective treatment. The following measures are also helpful:
Nasal irrigation with hypertonic saline solution may improve symptoms.
Antihistamines, oral or intranasal, improve allergic rhinitis symptoms and are most effective when taken prior to allergen exposure. Antihistamines are ideal for individuals with mild and intermittent symptoms. Common side effects include sedation and dry mouth and eyes, although second-generation antihistamines generally have a better sedation profile.
Intranasal steroids are highly effective and improve nasal congestion more effectively than antihistamines. They are often recommended as the initial therapy option for moderate to severe symptoms. They need to be used regularly as effects start about a week after initiation.
Leukotriene antagonists (zileuton) and leukotriene receptor antagonists (montelukast, zafirlukast) help decrease nasal and ocular inflammation.
Nasal cromolyn inhibits mast cell mediator release. It is most effective when taken before allergen exposure and is less effective in preventing nasal symptoms than nasal steroids. It can be used during pregnancy.
Nasal decongestant sprays should only be used temporarily (3 days). Prolonged use may result in a “rebound” effect, in which nasal congestion worsens upon withdrawal of medication. These medications are effective prior to elevation gain (e.g., on mountains, in airplanes) or before initiating nasal steroid use.
Oral decongestants, such as pseudoephedrine, are effective in relieving acute nasal congestion. Caution must be taken in hypertensive patients.
Nasal ipratropium bromide may be most helpful in children needing an alternative to steroids, and it is highly effective in treating rhinorrhea without nasal congestion.
Nonsteroidal anti-inflammatory drugs (NSAIDs) (short-term use) improve systemic sequelae.
Symptomatic treatment with antihistamines and decongestants, and NSAIDs for systemic sequelae, such as cough, congestion, and fatigue, may be helpful over the short term. Most cases of rhinosinusitis resolve spontaneously within 10 days.
Nasal irrigation with hypertonic saline solution may improve symptoms.
In presumed cases of acute bacterial sinusitis, antibiotics may be effective but are not always necessary for initial therapy.
Amoxicillin, trimethoprim-sulfamethoxazole, and doxycycline are initial options for acute bacterial sinusitis. A moxicillin-clavulanate and select cephalosporins/fluoroquinolones are needed to cover resistant bacteria. Treat for 10 to 14 days.
Recurrent/chronic disease requires aggressive treatment with intranasal steroids and nasal saline flushes. A CT scan of the sinuses may be indicated.
Dietary history should be evaluated, as nutritional factors may influence allergies. For example, high dairy intake may contribute to symptoms, and in one study, milk allergy was significantly more common in those with chronic polyposis. Children with allergic rhinitis may be more likely to be vitamin D deficient. Mediterranean-style diets may be protective due to higher intake of antioxidant-rich vegetables, fruits, legumes, and whole grains and limited meat and refined grain intake. ,
Limited evidence suggests that longer duration of breastfeeding and avoidance of early introduction of potentially allergenic foods may reduce the likelihood of allergic sensitization. In an Italian study, new mothers were advised to breastfeed 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 breastfeed 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.
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 children and of liver by adolescents 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.
Limited evidence also suggests that blood levels of vitamins C and E are lower in children with chronic sinusitis than in controls. The intake of citrus fruit or kiwi fruit, both high in vitamin C, has been associated with lower frequency of rhinitis in children. A study with 4,554 Korean schoolchildren found that vitamin C intake was associated with reduced symptoms of allergic rhinitis. The antioxidant capacity of vitamin C may suppress secretion of superoxide anions.
Vitamin E has immunologic effects that might improve rhinitis symptoms, including suppression of neutrophil migration and inhibition of immunoglobulin E (IgE) production. Vitamin E intake from foods was protective against hay fever in an adult population. Patients with hay fever taking vitamin E supplements during pollen season experienced lower nasal symptom scores than those of placebo takers. Additional studies are needed to determine if food or supplemental sources of ascorbic acid and vitamin E benefit sufferers of allergic rhinitis.
Studies suggest that, among individuals with allergic rhinitis, dietary fatty acids and antioxidants may 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. - Studies with children have found allergic rhinitis positively correlates with high-fat and low-carbohydrate diets.
A botanical treatment called butterbur ( Petasites hybridus) significantly reduces both histamine and leukotriene production in sufferers of allergic rhinitis. Benefits have been shown to be similar to those of a prescription antihistamine (cetirizine), without causing cetirizine’s sedating side effects. ,
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 breastfeed (and withhold any dairy products for 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.
- Meltzer EO, Blaiss MS, Derebery MJ, et al. Burden of allergic rhinitis: results from the Pediatric Allergies in America survey. J Allergy Clin Immunol. 2009;124(3 Suppl):S43-70. [PMID:19592081]
- Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. 2004;114(6 Suppl):155-212. [PMID:15577865]
- Fokkens W, Lund V, Mullol J, et al. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology. 2007;45(2):97-101. [PMID:17708455]
- Matheson MC, Dharmage SC, Abramson MJ, et al. Early-life risk factors and incidence of rhinitis: results from the European Community Respiratory Health Study--an international population-based cohort study. J Allergy Clin Immunol. 2011;128(4):816-823.e5. [PMID:21752439]
- Codispoti CD, Levin L, LeMasters GK, et al. Breast-feeding, aeroallergen sensitization, and environmental exposures during infancy are determinants of childhood allergic rhinitis. J Allergy Clin Immunol. 2010;125(5):1054-1060.e1. [PMID:20392478]
- Saulyte J, Regueira C, Montes-Martínez A, et al. Active or passive exposure to tobacco smoking and allergic rhinitis, allergic dermatitis, and food allergy in adults and children: a systematic review and meta-analysis. PLoS Med. 2014;11(3):e1001611. [PMID:24618794]
- Strachan DP. Hay fever, hygiene, and household size. BMJ. 1989;299(6710):1259-60. [PMID:2513902]
- Fuertes E, Brauer M, MacIntyre E, et al. Childhood allergic rhinitis, traffic-related air pollution, and variability in the GSTP1, TNF, TLR2, and TLR4 genes: results from the TAG Study. J Allergy Clin Immunol. 2013;132(2):342-52.e2. [PMID:23639307]
- Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. Am Fam Physician. 2004;70(9):1685-92. [PMID:15554486]
- Bousquet J, Heinzerling L, Bachert C, et al. Practical guide to skin prick tests in allergy to aeroallergens. Allergy. 2012;67(1):18-24. [PMID:22050279]
- Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc. 2011;86(5):427-43. [PMID:21490181]
- Kaszuba SM, Baroody FM, deTineo M, et al. Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis. Arch Intern Med. 2001;161(21):2581-7. [PMID:11718589]
- Hendaus MA, Jomha FA, Ehlayel M. Allergic diseases among children: nutritional prevention and intervention. Ther Clin Risk Manag. 2016;12:361-72. [PMID:27022267]
- Wei JL. Chronic nasal dysfunction in children: Allergic rhinitis? Infectious? What to do if neither? Curr Opin Otolaryngol Head Neck Surg. 2015;23(6):491-8. [PMID:26488532]
- Lill C, Loader B, Seemann R, et al. Milk allergy is frequent in patients with chronic sinusitis and nasal polyposis. Am J Rhinol Allergy . 2011;25:221-224.
- Bener A, Ehlayel MS, Bener HZ, et al. The impact of Vitamin D deficiency on asthma, allergic rhinitis and wheezing in children: An emerging public health problem. J Family Community Med. 2014;21(3):154-61. [PMID:25374465]
- de Batlle J, Garcia-Aymerich J, Barraza-Villarreal A, et al. Mediterranean diet is associated with reduced asthma and rhinitis in Mexican children. Allergy. 2008;63(10):1310-6. [PMID:18782109]
- Chatzi L, Kogevinas M. Prenatal and childhood Mediterranean diet and the development of asthma and allergies in children. Public Health Nutr. 2009;12(9A):1629-34. [PMID:19689832]
- Marini A, Agosti M, Motta G, et al. Effects of a dietary and environmental prevention programme on the incidence of allergic symptoms in high atopic risk infants: three years' follow-up. Acta Paediatr Suppl. 1996;414:1-21. [PMID:8831855]
- Farchi S, Forastiere F, Agabiti N, et al. Dietary factors associated with wheezing and allergic rhinitis in children. Eur Respir J. 2003;22(5):772-80. [PMID:14621084]
- Huang SL, Lin KC, Pan WH. Dietary factors associated with physician-diagnosed asthma and allergic rhinitis in teenagers: analyses of the first Nutrition and Health Survey in Taiwan. Clin Exp Allergy. 2001;31(2):259-64. [PMID:11251627]
- Linday LA, Dolitsky JN, Shindledecker RD. Nutritional supplements as adjunctive therapy for children with chronic/recurrent sinusitis: pilot research. Int J Pediatr Otorhinolaryngol. 2004;68(6):785-93. [PMID:15126020]
- Unal M, Tamer L, Pata YS, et al. Serum levels of antioxidant vitamins, copper, zinc and magnesium in children with chronic rhinosinusitis. J Trace Elem Med Biol. 2004;18(2):189-92. [PMID:15646267]
- 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(4):283-8. [PMID:10722767]
- Seo JH, Kwon SO, Lee SY, et al. Association of antioxidants with allergic rhinitis in children from seoul. Allergy Asthma Immunol Res. 2013;5(2):81-7. [PMID:23450181]
- Nagel G, Nieters A, Becker N, et al. The influence of the dietary intake of fatty acids and antioxidants on hay fever in adults. Allergy. 2003;58(12):1277-84. [PMID:14616103]
- 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(6):654-8. [PMID:15237767]
- Calder PC. N-3 polyunsaturated fatty acids, inflammation, and inflammatory diseases. Am J Clin Nutr. 2006;83(6 Suppl):1505S-1519S. [PMID:16841861]
- Tuñón MJ, García-Mediavilla MV, Sánchez-Campos S, et al. Potential of flavonoids as anti-inflammatory agents: modulation of pro-inflammatory gene expression and signal transduction pathways. Curr Drug Metab. 2009;10(3):256-71. [PMID:19442088]
- Kim SY, Sim S, Park B, et al. High-Fat and Low-Carbohydrate Diets Are Associated with Allergic Rhinitis But Not Asthma or Atopic Dermatitis in Children. PLoS ONE. 2016;11(2):e0150202. [PMID:26919190]
- Thomet OA, Simon HU. Petasins in the treatment of allergic diseases: results of preclinical and clinical studies. Int Arch Allergy Immunol. 2002;129(2):108-12. [PMID:12403927]
- Schapowal A, Petasites Study Group. Randomised controlled trial of butterbur and cetirizine for treating seasonal allergic rhinitis. BMJ. 2002;324(7330):144-6. [PMID:11799030]
- Schapowal A, Study Group. Treating intermittent allergic rhinitis: a prospective, randomized, placebo and antihistamine-controlled study of Butterbur extract Ze 339. Phytother Res. 2005;19(6):530-7. [PMID:16114089]