lowing: Nasal congestion (stuffiness), rhinorrhea, and postnasal drainage (Nozad et al., 2010). This is a diagnosis of exclusion; thus, specific etiologies must be excluded (e.g., allergic, infec - tious, pharmacologic, structural, hormonal, vasculitis, metabolic, and atrophic causes). Clinically, it is distinguished from allergic rhinitis by the following: ● Onset at a later age. ● Absence of nasal and ocular itching and prominent sneezing. ● Nasal congestion and postnasal drainage as prominent symp- toms. ● Perennial symptoms. Typical triggers in nonallergic rhinitis include irritant odors and intense fragrances, such as tobacco smoke, perfumes, diesel and car exhaust (i.e., patients become congested when sitting in traf- fic), cleaning products, newsprint, temperature changes, and al - coholic beverages (John Hopkins Medicine, 2022). While a thorough history and physical examination are required to establish the clinical diagnosis of rhinitis, further diagnostic testing is usually necessary to confirm that underlying allergies are causing the rhinitis. Skin-prick testing is the primary method for identifying specific allergic triggers of rhinitis. Skin-prick test - ing involves placing a drop of a commercial extract of a specif-
ic allergen on the skin of the forearm or back, then pricking the skin through the drop to introduce the extract into the epidermis. Within 15 to 20 minutes, a wheal-and-flare response (an irregular blanched wheal surrounded by an area of redness) will occur if the test is positive (John Hopkins Medicine, 2022). Testing is typically performed using the allergens relevant to the patient’s environ- ment (e.g., pollen, animal dander, molds, and house dust mites). A reasonable alternative to skin-prick testing is allergen-specific IgE tests (e.g., radioallergosorbent tests [RASTs]) that provide an in vitro measure of a patient’s specific IgE levels against particu - lar allergens (John Hopkins Medicine, 2022). However, skin-prick tests are generally considered more sensitive and cost-effective than allergen-specific IgE tests and have the advantage of imme - diate results. Besides a basic exam of the nasal passages, the pa- tient may also have a nasal endoscopy. This test involves looking at the inside of the nasal passages with a thin, fiber-optic view - ing instrument called an endoscope. The provider will pass the fiber-optic endoscope through the nostrils to examine the nasal passages and sinuses. Lastly, a computed tomography (CT) scan, a computerized X-ray technique that produces images of the si- nuses, may be utilized.
PHARMACOLOGICAL/ NONPHARMACOLOGICAL
Allergic rhinitis The treatment goal for allergic rhinitis is the relief of symptoms. Therapeutic options to achieve this goal include avoidance mea- sures, oral antihistamines, intranasal corticosteroids, leukotriene receptor antagonists, and allergen immunotherapy. Other thera- pies that may be useful in select patients include decongestants and oral corticosteroids. If the patient’s symptoms persist despite appropriate treatment, referral to an allergist should be consid- ered. Allergic rhinitis and asthma appear to represent a combined airway inflammatory disease; therefore, asthma treatment is also an important consideration in patients with allergic rhinitis. The first-line treatment of allergic rhinitis involves the avoidance of relevant allergens (e.g., house dust mites, molds, pets, pollens) and irritants (e.g., tobacco smoke). Patients allergic to house dust mites should be instructed to use allergen-impermeable covers for bedding and to keep the relative humidity in the home below 50% (to inhibit mite growth). Pollen exposure can be decreased by keeping windows closed, using an air conditioner, and restricting the time spent outdoors during peak pollen seasons. Removing animals from home is recommended for patients with reactions to animal dander and usually results in a significant reduction in symptoms within four to six months (Akhouri et al., 2022). Howev- er, compliance with this recommendation is poor; therefore, using high-efficiency particulate air (HEPA) filters and restricting the an - imal from the bedroom or keeping it outdoors may be needed to decrease allergen levels. Strategies to reduce exposure to mold allergens include cleaning with fungicides, dehumidifying to less than 50%, and HEPA filtration. These avoidance tactics can suc - cessfully improve the symptoms of allergic rhinitis, and patients should be instructed to use a combination of methods for optimal results (Akhouri et al., 2022). Nonsedating, second-generation oral antihistamines (e.g., deslo- ratadine [Aerius], fexofenadine [Allegra], and loratadine [Claritin]), cetirizine (Zyrtec), and levocetirizine (Xyzal) are the first-line phar - macological treatments recommended for all patients with aller- gic rhinitis (Akhouri et al., 2022). These agents have been found to effectively reduce sneezing, itching, and rhinorrhea when tak- en regularly during maximal symptoms or before exposure to an allergen. Although the older (first- generation) sedating antihis - tamines (e.g., diphenhydramine, chlorpheniramine) are also ef- fective in relieving symptoms, they have been shown to impact cognition and functioning adversely, so they are not consistently recommended for the treatment of allergic rhinitis; however, they are appropriate for use at bedtime (Akhouri et al., 2022).
Intranasal corticosteroids are first-line therapeutic options for pa - tients with mild persistent or moderate/severe symptoms, and they can be used alone or in combination with oral antihistamines (Dykewicz et al., 2017). When used regularly and correctly, intra- nasal corticosteroids effectively reduce inflammation of the nasal mucosa and improve mucosal pathology. Studies and meta- anal- yses have shown that intranasal corticosteroids are superior to an- tihistamines and leukotriene receptor antagonists in controlling the symptoms of allergic rhinitis, including nasal congestion and rhinorrhea. They may also improve ocular symptoms and reduce lower airway symptoms in patients with concurrent asthma and allergic rhinitis. Examples of intranasal corticosteroids include fluticasone propio - nate (Flonase), triamcinolone acetonide (Nasacort), mometasone furoate (Nasonex), ciclesonide (Omnaris), and budesonide (Rhi- nocort). Since the proper nasal spray application is required for optimal clinical response, patients should be counseled on the appropriate use of these intranasal devices. Ideally, intranasal corticosteroids are best started before exposure to relevant al- lergens, and because their peak effect may take several days to develop, they should be used regularly. The most common side effects of intranasal corticosteroids are nasal irritation and stinging. However, these side effects can usu- ally be prevented by aiming the spray slightly away from the nasal septum. It is important to note that most patients with allergic rhinitis pre- senting to their primary care physician have moderate to severe symptoms and will require an intranasal corticosteroid. The leukotriene receptor antagonists (LTRAs) montelukast and zafirlukast are also effective in treating allergic rhinitis; however, they do not appear to be as effective as intranasal corticosteroids. Although one short-term study found the combination of LTRAs and antihistamines to be as effective as intranasal corticosteroids, longer-term studies have found intranasal corticosteroids to be more effective than the combination of LTRAs and antihistamines for reducing nighttime and nasal symptoms. Leukotriene receptor antagonists should be considered when oral antihistamines and intranasal corticosteroids are not well tolerat- ed or are ineffective in controlling allergic rhinitis symptoms. If combined pharmacological therapy with oral antihistamines, in- tranasal corticosteroids, and LTRAs is neither effective nor toler- ated, then allergen immunotherapy should be considered (Dyke- wicz et al., 2017).
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