SCENARIO

A 10 year old boy is taken by his mother to the community health center. He
has suffered from an on-going cold for 1 year. The symptom is complained almost
every day and is often accompanied with mucus secretion in his throat. This boy
reported having difficulty in breathing since he was toddler.
INTRODUCTION
Rhinitis is a reaction that occurs in the eyes, nose and throat when airborne
irritants which are the allergens trigger the release of histamine. Histamine released
will cause inflammation and fluid production in the fragile linings of nasal passages,
sinuses, and eyelids. There are actually two categories of rhinitis. First is allergic
rhinitis and second is non-allergic rhinitis. Allergic rhinitis can be furthered divided
into seasonal and perennial type. Seasonal allergic rhinitis occurs particularly during
pollen seasons while the perennial one occurs throughout the year. Besides that,
non-allergic rhinitis has quite a number of types. They are vasomotor rhinitis (irritant
rhinitis), eosinophilic, rhinitis medicamentosa, neutrophillic rhinosinusitis, structural
rhinitis, nasal polyps and primary vasomotor instability. Some disorders may be
associated with allergies. These will include eczema and asthma.
SYMPTOMS
Allergic rhinitis is characterized by paroxyms of sneezing, rhinorrhea, nasal
obstruction, and itching of the eyes, nose, and palate. It is also frequently associated
with postnasal drip, cough, irritability, and fatigue. Allergic rhinitis is classified as
seasonal if symptoms occur at particular time of the year, or perennial if symptoms
occur year around.
Perennial allergic rhinitis is associated with nasal symptoms, which occur for
more than nine months of the year. Perennial allergic rhinitis usually reflects allergy
to indoor allergens like dust mites, cockroaches, or animal dander.

PATHOPHYSIOLOGY OF ALLERGY REACTION (TYPE 1 HYPERSENSITIVITY)
Allergic rhinitis involves inflammation of the mucous membranes of the nose,
eyes, Eustachian tubes, middle ear, sinuses, and pharynx. The nose invariably is
involved, and the other organs are affected in certain individuals. Inflammation of the
mucous membranes is characterized by a complex interaction of inflammatory
mediators but ultimately is triggered by an immunoglobulin E (IgE)mediated
response to an extrinsic protein.
The tendency to develop allergic, or IgE-mediated, reactions to extrinsic
allergens has a genetic component. In susceptible individuals, exposure to certain
foreign proteins leads to allergic sensitization, which is characterized by the
production of specific IgE directed against these proteins. This specific IgE coats the
surface of mast cells, which are present in the nasal mucosa. When the specific
protein is inhaled into the nose, it can bind to the IgE on the mast cells, leading to
immediate and delayed release of a number of mediators.
The mediators that are immediately released include histamine, tryptase,
chymase, kinins, and heparin. The mast cells quickly synthesize other mediators,
including leukotrienes and prostaglandin D2. These mediators, via various
interactions, ultimately lead to the symptoms of rhinorrhea (ie, nasal congestion,
sneezing, itching, redness, tearing, swelling, ear pressure, postnasal drip). Mucous
glands are stimulated, leading to increased secretions. Vascular permeability is
increased, leading to plasma exudation. Vasodilatation occurs, leading to congestion
and pressure. Sensory nerves are stimulated, leading to sneezing and itching.
Over 4-8 hours, these mediators, through a complex interplay of events, lead
to the recruitment of other inflammatory cells to the mucosa, such as neutrophils,
eosinophils, lymphocytes, and macrophages. This results in continued inflammation,
termed the late-phase response. The symptoms of the late-phase response are
similar to those of the early phase, but less sneezing and itching and more
congestion and mucus production tend to occur. The late phase may persist for
hours or days. Systemic effects, including fatigue, sleepiness, and malaise, can
occur from the inflammatory response.

DIFFERENTIAL DIAGNOSIS
There are a few differential diagnoses for this allergic disease. They are
concluded into a table as listed below.
Characteristics Perennial
allergic rhinitis
Non-allergic
rhinitis
Vasomotor
rhinitis
Nasal polyps
Cold(Rhinorrhea) + + + +
Male + + + +
10 years old + + + -
Secretion in
throat
+ + + -
Difficult
respiration
(history)
+ - - -
Examination Skin prick test IgE specific
test
Skin prick test endoscopy,
CT scan
Other clinical
manifestation
Itching,
sneezing,
increase of
nose
sensitivity,
sore throat
Nasal
congestion,
sneezing
Nasal
congestion,
sneezing,
fever, pain,
non-allergic
disease
Sneezing, loss
of taste &
smell
(hyposmia),
itching,
purulent
rhinorrhea



PHYSICAL EXAMINATION & TEST
One of the physical examination that can be done in this scenario is by using
anterior rhinoscopy with high illumination using head lamp or endoscopy. Things that
should attract the physician are:
1. Mucosa which can be inflamed or reddened or pale blue.
2. Watery discharge
3. Enlargement of turbinate
4. Nasal polyps which characterized by rounded shape, white & glistening
masses.
Other symptoms that might be found together are:
1. Mouth breathing
2. Allergic salute
3. A nasal crease
4. Allergic shiners
5. Frontal headache
6. Hyposmia
7. Ocular symptoms

PREVENTION & TREATMENT
The best treatment in any disease that involved in the allergens is of course to
avoid the contact with the allergen itself. The most common allergen that result in the
allergic rhinitis such as house dust mites, pollen, mold, and pets. Besides that,
corticosteroid also can be used which react as vasoconstrictor and anti-
inflammatory. They control the 4 major symptoms of rhinitis such as sneezing,
itching, rhinorrhea & congestion). They are effective as monotherapy although they
do not significantly affect ocular symptoms. Studies have shown that nasal steroids
are more effective than monotherapy with nasal cromolyn or antihistamines.
Anti-histamine helps in by control the sneezing, rhinorrhea and itching. They
also provide inadequate relief from nasal obstruction. There are two types of
antihistamine, first-generation & second-generation of histamine. First-generation
antihistamines are effective in reducing most symptoms of allergic rhinitis, but they
also produce a number of adverse effects with prolonged use. Patients may
experience cognitive impairment and driving skills may be affected. Administration at
bed time may help with the drowsiness but the sedation and cognitive impairment
may continue until next day.
Second-generation antihistamines often referred as non-sedating
antihistamines. They compete with histamine for histamine receptor type 1 (H1)
receptor sites in blood vessels, GI tract and respiratory tract. This will inhibit
physiologic effects that histamines normally induce at the H1 receptor sites. All are
efficacious in controlling symptoms of allergic rhinitis but do not significantly improve
nasal congestion.
Immunotherapy is like vaccination to against the allergies. Immunotherapy
makes the immune system dull to react to allergen. In long term, immunotherapy can
help in reduce the use of antihistamine. In fact, immunotherapy builds up the
tolerance of the body to specification of allergens. This means that the body will not
overreact to them and cause the allergic reactions.
This is process on how to do the immunotherapy to the patients. First of all,
confirmed the allergens before they are injected into patients body. Only small
amount of the allergens injected over the course of many month, and periodically
increasing the amount of allergens. Immunotherapy can last for about 3 to 5 years..
The benefits can last for more than 3 years after stopping the injections.
However, the immunotherapy cannot be done if there is the risk of having
anaphylaxis. If patients suffer from lung disorder, uncontrolled asthma, uncontrolled
hypertension, heart problem, and kidney failure, it is not advisable for them to
undergo this therapy. The same precaution happens to pregnancy women as well.
Immunotherapy may be considered more strongly with severe disease, poor
response to other management options, and the presence of comorbid conditions or
complications. Immunotherapy often combined with pharmacotherapy and
environmental control. The administration of allergens should be for the one which is
known to be sensitive to patient and present in the patients environment and cannot
be easily avoided. There are also a number of contraindication in immunotherapy &
need to be considered.
Our group has selected a few drugs that might help in the treatment of allergic
rhinitis. They are listed down below altogether with their effectiveness in treating the
symptoms.


Agent Sneezing Itching Congestion Rhinorrhea Eye
symptoms
Oral
antihistamine
++ ++ +/- ++ ++
Nasal
antihistamine
+ + +/- + -
intranasal
corticosteroids
++ ++ ++ ++ +
oral
decongestant
- - + - -
intranasal
decongestant
- - ++ - -
Intranasal
Mast cell
destabilize
+ + + + -
Topical
anticholinergic
- - - ++ -
If the symptoms range from persistent mild to moderate, the treatment can be
start by prescribing the oral non-sedating antihistamine. This is the first line
treatment that can be used for the allergic rhinitis. Then, the topical intranasal
corticosteroid can also be used together with the antihistamine. Topical intranasal
antihistamine and nasal cromolyn can also be considered as the treatment. If the
symptoms are more severe, the combination of topical intranasal corticosteroid and
oral non-sedating antihistamine might help. If needed, this can be accompanied with
a short course of oral corticosteroids. If the watery discharges are quite copious,
intranasal anticholinergic can be considered as the treatment.

PROGNOSIS
People with allergic rhinitis mat experience sleep disorders and daytime
fatigue. They might attribute this to medication but congestion might responsible too.
Asthma and allergies often coexist and the allergic response plays a strong role in
childhood asthma. Aggressive treatment of allergies in children with asthma can
lower the risk of asthma attacks. Patients with allergies also have a high risk of
eczema and nasal polyps.
Chronic rhinitis can cause swelling in the turbinate, which may become
persistent. If the turbinate hypertrophy develops, it causes persistent nasal
congestion and pressure and headache in the middle of the face and forehead. This
condition may require surgery. Chronic nasal obstruction from year-round allergies
can affect a childs appearance. If the child can only breath through the mouth, the
continual force of passing through the oral cavity can cause changes in facial
development. Such changes may include an elongated face and an overbite from
teeth coming in at an abnormal angle. Chronic rhinitis can cause headaches and
also affect a childs sleep, concentration, hearing, appetite and growth.