Allergic Rhinitis

Allergic rhinitis is the proper name for the lay terms of “sinus,” “allergies,” or “hayfever.”  The term allergic refers to the altered immune function wherein sensitive tissue located in the nose, throat and conjunctiva is exposed to foreign proteins.  This results in an antigen-antibody reaction.  The antigen would be the foreign protein, such as cedar pollen.  Antibody (IgE) is made by the lymph tissue in the upper airway and eye.  As a result mast cells cause the release of IgE.

The diagnosis is based on a history of seasonal or continuous symptoms of nasal and ocular itching, sneezing, nasal stuffiness, clear nasal drainage, and cough.  The diagnosis can be confirmed by demonstration of IgE antibodies by either skin testing or radioallergosorbent testing (RAST). Skin testing is preferred because of greater sensitivity and decreased cost.

Treatment is stepwise with antihistamines as the first step followed by nasal steroids, decongestants, and anticholinergics.  Immunotherapy can be introduced if the patient fails to respond or cannot tolerate medication.

Older antihistamines are available over the counter, but are commonly very sedating and therefore poorly tolerated.  An example would be Benadryl.  The newer drugs such as Claritin (loratadine), Allegra (fexofenadine), and Zyrtec (cetirizine) are non-sedating and better tolerated.

Common nasal steroids sprays are Flonase (fluticasone) or Triamcinolone (Nasacort).  Pseudoephedrine may be added orally when nasal steroids and antihistamines are inadequate, but Sudafed taken regularly can disrupt sleep, aggravate migraine, and provoke anxiety and panic symptoms.  Claritin, for example, comes as Claritin D, which has pseudoephedrine added as a decongestant. Topical agents such as Afrin nose spray should be avoided as overuse can lead to rebound congestion and rhinitis medicamentosa. 

Patients with severe symptoms should consider referral to an allergist for immunotherapy (allergy shots).