A Case of Allergic Rhinitis

A 25-year-old male patient presents to the outpatient with history of bilateral nasal obstruction for the past 2 years. The obstruction has been on and off but has become continuous over the past 15 days. It is sometimes associated with headache.

There is also history of excessive sneezing and nasal discharge. The discharge is thin and watery, not foul smelling or blood-stained and is occasionally associated with watering of the eyes. There is history of itching in the nose, palate and eyes. There is no history of fever. The symptoms are often triggered off by exposure to dust.

Examination

The external appearance of the nose is normal. There is no abnormality in the vestibule. Anterior rhinoscopy reveals serous discharge in both nasal cavities. The inferior turbinates are hypertrophied, bluish and boggy on both sides. There is no septal deviation. There is no tenderness over the paranasal sinuses.

The ear, throat and neck are normal.

Questions

Answer the following questions before you go on to read the case discussion below.

• What is your diagnosis?
• What investigations are required for this condition?
• How will you manage this case?
• Does it require surgical management?

Discussion

Bilateral nasal obstruction is caused by conditions that affect both nasal cavities – inflammatory conditions like rhinitis and sinusitis, polyps and deviated nasal septum. While the presence of nasal discharge suggests an inflammatory condition like rhinitis or sinusitis, watery nasal discharge is seen in the early part of infective rhinitis, allergic rhinitis and in CSF rhinorrhea.

History of excessive sneezing, watering of the eyes,itching in the nose, eyes and throat and onset or worsening of symptoms with exposure to dust all suggest allergic rhinitis.

The serous nasal discharge and hypertrophied inferior turbinates seen on examination also indicate allergy. The nasal mucosa is usually pale in this condition, but acute exacerbation of symptoms often causes the turbinates to become boggy and bluish.

Diagnosis

Allergic rhinitis

Management

While allergic rhinitis is usually diagnosed clinically, investigations are required to detect the allergens responsible for it. The following tests are performed:

• Skin tests
• RAST (radioallergosorbent test)
• Estimation of serum IgE
• Absolute eosinophil count – raised

As for treatment, allergen avoidance, when possible, is the best measure. Here is a look at other treatment options.

Medical management

• Antihistamines – These are helpful in controlling symptoms caused by allergy. First generation antihistamines cause sedation, so it is better to prescribe second generation antihistamines like levocetrizine, fexofenadine or loratidine.
• Nasal decongestants – These are occasionally used to relieve congestion and nasal obstruction.
• Topical nasal steroids – Steroids are powerful anti-inflammatory agents and are used in long standing cases. Topical steroid sprays help avoid the systemic side effects of oral steroids. The agents used are fluticasone, mometasone, budesonide and beclomethasome.
• Leukotriene receptor antagonists – These act similarly to antihistamines but against leukotriene receptors. Eg – monteleukast.
• Cromolyn sodium – This is a mast cell stabilizer but only helps prevent episodes of allergy and has to be given before the onset of symptoms.

Immunotherapy

Immunotherapy is a form of desensitization where incremental doses of the causative allergen are given as injections. This therapy works when the allergy is caused by a single or few allergens and they are identified accurately.

Surgical treatment

Nasal allergy itself does not require any surgical treatment. But the presence of other pathology like polyps, or coexisting conditions like sinusitis or DNS may require surgical correction.

See ENT cases for more case reports and discussions on diagnosis and management.

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