The patient’s unmet needs (PUNs)
A 43-year-old man attends complaining bitterly about his bunged up nose. He has symptoms all year round. ‘I’ve followed all the advice and I’ve tried everything,’ he says. Examination reveals poor nasal airways, with fleshy masses dimly visible in both nostrils. ‘Everyone tells me it’s an allergy,’ he continues, ‘So I’d like some allergy tests. And there must be something else you can give me – or do I need to see a specialist?’
The doctor’s educational needs (DENs)
What is the role of allergy tests in managing perennial rhinitis? How often do they change management – is allergen avoidance likely to be feasible or effective?
In adult rhinitis, approximately one third of cases have an allergic cause. Allergy testing is useful in distinguishing between allergic and non-allergic rhinitis, each of which has different treatment options. Allergy testing will identify the allergic triggers, allowing for avoidance (if possible) and allergen-specific immunotherapy. Allergy tests involve either skin prick testing or specific IgE blood test, also known as RAST (radioallergosorbent testing).
When symptoms of allergic rhinitis are perennial, then perennial allergens such as house dust mite, animal dander or fungal spores are the cause. Seasonal symptoms are usually due to pollens but can also be caused by fungal spores.
Allergen avoidance in perennial allergic rhinitis has variable benefit depending on the allergen involved.
- If symptoms are entirely due to a pet allergy, then re-housing the pet can improve symptoms dramatically.
- House dust mite avoidance is more problematic. Avoidance measures such as mattress covers, pillow covers, washing sheets at high temperature, freezing pillows, removing carpets and using vacuum cleaners with HEPA filters are commonly recommended and anecdotally can be beneficial.
- Unfortunately, all large studies and Cochrane analyses of dust mite avoidance have failed to show significant improvements in symptoms.
- There is no effective way of avoiding fungal spores or pollens.
Allergy testing can also help making decisions about referral to allergy specialists to consider allergen-specific immunotherapy.
What are the standard medical therapeutic options available and why might these treatments fail? What is the role and effectiveness of antihistamines?
Standard therapeutic options for allergic rhinitis include oral antihistamines (preferably non-sedating) and topical nasal steroids. Oral antihistamines alone have a modest effect and will control only the mildest cases. Topical antihistamines for the nose are also effective, but until better quality comparative data is available, oral antihistamines tend to be preferred in routine clinical practice.
Topical nasal steroids are the single best treatment for allergic rhinitis and will benefit most patients. Common reasons for failure are poor technique – the majority of the dose ends up swallowed rather than being deposited on the nasal mucosa – and when the rhinitis is of infective aetiology.
For non-allergic rhinitis, antihistamines and topical steroids can be used but there may also be a role for:
- topical anticholinergics such as ipratropium – when copious watery rhinorrhoea is the predominant symptom or
- sympathomimetic decongestants such as pseudoephedrine – when nasal congestion is prominent).
If using sympathomimetics, it is important to limit treatment to two weeks or less to avoid rhinitis medicamentosa.
More recently, the combination of topical nasal steroid (fluticasone) and topical antihistamine (azelastine) in a single spray (Dymista) has shown promising results in both allergic and non-allergic rhinitis and can be considered when the nasal steroid alone has not had sufficient effect.
The non-pharmacological option of nasal douching can also be of additional benefit particularly in clearing out thick mucus prior to the application of nasal steroids. They may also be helpful in removing allergen from the nasal mucosal. Low volume hypertonic sea water sprays and high volume isotonic saline solutions are commercially available.
When should leukotriene receptor antagonists be considered?
When the other standard treatments have failed to achieve adequate control, the addition of montelukast or zafirlukast can be of benefit but only in a minority of patients. A trial of one month is usually sufficient to determine whether the patient is a ‘responder’.
Leukotriene antagonists may be of particular benefit in those patients with nasal polyposis and aspirin sensitivity (see below).
How can the GP distinguish between swollen turbinates and nasal polyps? Does being able to make this discrimination significantly alter management?
Nasal polyps are pearly grey in appearance, whereas a swollen turbinate is usually of a similar colour to the surrounding inflamed nasal mucosa. A gentle prod with an orange stick is a simple test to distinguish the two. If it is a polyp, the patient will not feel it, but a swollen turbinate will be exquisitely sensitive.
Nasal polyps are virtually always non-allergic in origin. Traditionally, they were considered to be associated with chronic allergic inflammation and were commonly referred to as ‘allergic polyps’. However, the simple observation that most people with allergic rhinitis do not have polyps and those patients with nasal polyposis are most commonly non-atopic, suggests otherwise. Anosmia is a common associated symptom.
The aetiology of the polyp is not clear. Nasal polyps are frequently associated with asthma and aspirin sensitivity (Samter’s Triad).
Surgery is an option for dealing with polyps, but they always have the potential to re-grow. Nasal steroids are of particular importance in slowing down the rate of re-growth. They are very useful in delaying, and sometimes completely avoiding the need for surgery. If the polyps are particularly resistant to standard treatment and the patient is aspirin-sensitive, then aspirin desensitisation by an allergy specialist can be helpful.
Which patients require referral? Is surgery likely to be the outcome in such cases and, if so, how successful is this?
Referral to an allergy specialist can be useful if an allergic trigger is suspected. If the allergen is unavoidable, specialist treatments such as desensitisation.
Immunotherapy provides long-term reduction, for many years after the course, in symptom severity and requirement for additional standard medications.
Surgical input can be useful in non-allergic rhinitis when a structural cause such as deviated nasal septum, a chronic sinusitis or severe nasal polyposis is suspected, all of which might be amenable to corrective surgery or functional endoscopic sinus surgery (FESS).
- Rhinitis can be allergic or non-allergic
- Allergic rhinitis can be seasonal or perennial depending on the allergens involved
- Non-allergic rhinitis has a range of aetiologies including infective, vasomotor/idiopathic, structural, atrophic, hormonal and drug-induced
- Nasal polyps are almost always non-allergic
- Allergy testing can help distinguish allergic from non-allergic rhinitis and identify the culprit allergens
- Managing allergic rhinitis involves three treatment modalities:
- Allergen avoidance (if possible)
- Standard medical treatments
- Immunotherapy (refer to allergy specialist)
- Non-allergic rhinitis can also respond to the standard medical treatments but a surgical opinion can be useful when there are polyps, structural problems and chronic sinusitis
Dr Rubaiyat Haque is a consultant allergist at Guy’s and St Thomas’ Hospital.
Conflicts of interest: Dr Haque received support from Meda Pharmaceuticals UK to attend an international allergy conference in June 2013.
Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical and Experimental Allergy, 2008; 38 (1): 19-42
Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clinical Experimental Allergy, 2008; 38 (2): 260-275
Walker SM, Durham SR, Till SJ et al. Immunotherapy for allergic rhinitis. Clinical Experimental Allergy, 2011; 41 (9): 1177-1200