GP - Allergic rhinitis

Question 1

Compare and contrast common cold and allergic rhinitis

Answer 1

• Acute onset of symptoms within minutes following allergen exposure in allergic rhinitis, but symptoms develop gradually in a common cold
• No fever in allergic rhinitis, but fever can be present in a common cold
• Itchy eyes in allergic rhinitis, but rare in a common cold
• Myalgia, arthralgia are uncommon in allergic rhinitis, but are common in common cold
• Thin, watery, clear mucus in allergic rhinitis, but thick, green mucus in a common cold
• Common cold usually takes 1 week to resolve, while allergic rhinitis usually goes away as soon as the patient is no longer exposed to the allergen

Question 2

What immunoglobulin is responsible for allergic rhinitis?

Answer 2

IgE

Question 3

What are the causes of allergic rhinitis?

Answer 3

• Genetics
• Environmental
  
  • House dust mites
  • Animal dander
  • Pollen
  • Occupational - e.g. working with latex gloves, flour, wood dust, lab animals

Question 4

Give 3 complications of allergic rhinitis

Answer 4

Impaired school and work performance

Sleep disturbance

Asthma (often co-exist with allergic rhinitis)

Sinusitis and nasal polyps

Question 5

What symptoms would a patient with allergic rhinitis present with?

Answer 5

Symptoms:

• Nasal congestion, nasal discharge, sneezing, itchy palate, itchy nose, itchy red eyes with increased tear secretion, cough, post-nasal drip - usually develop within minutes following allergen exposure (pollens, dust mites, animal dander, occupational)
• Mouth breathing
• Personal or FHx of atopy - allergic rhinitis (hayfever), asthma, eczema

Question 6

What signs would a a patient with allergic rhinitis present with?

Answer 6

Nasal intonation of voice

Allergic shiners - darkened eye shadows under lower eyelid due to chronic congestion

Horizontal nasal crease across the dorsum of nose (severe rhinitis)

Nasal mucosal swelling + greyish discoloration

Hypertrophic nasal turbinates

Question 7

Give 3 differential diagnoses of allergic rhinitis

Answer 7

Infective rhinitis - cough, fever, lymphadenopathy, purulent nasal discharge

(If nasal discharge is clear, unlikely to be infective)

Autonomic/ irritant rhinitis - symptoms follow a known physical exposure (e.g. changes in temperature or humidity, or with exercise), or chemical irritant exposure (e.g. perfumes, tobacco smoke, odours)

Question 8

What investigations can you request in GP for a patient with allergic rhinitis?

Answer 8

Skin prick test

OR

Measuring the level of serum IgE to allergens e.g. house dust mites, polle, animal dander

Question 9

What advice would you give to a patient with allergic rhinitis as a GP?

Answer 9

• Advice on allergen avoidance
  
  • For grass pollen allergy:
    
    • Avoid walking in open grassy areas, particularly during early morning and early evening
    • Keep windows shut in cars and buildings
  • For dust mite allergy:
    
    • Wash bedding and furry toys at least once a week at high temperatures
    • Fit blinds that can be wiped clean instead of curtains
    • Avoid use of carpets
  • For animal allergy:
    
    • Don’t allow animal in the house, if not possible, restrict their presence to bedrooms and kitchen
    • Wash the animal and any surfaces they are in contact with regularly
  • For occupational allergy:
    
    • Use latex-free gloves, wear protective clothing, or a dust mask
    • Ensure that their workplace is well-ventilated
• Advice on the use of nasal irrigation with saline

Question 10

What medications can you give to the patient with allergic rhinitis?

Answer 10

For mild-moderate symptom:

• 1st line - intranasal antihistamine / oral antihistamine e.g. cetirizine (PRN)

For moderate-severe symptoms, or if initial drug treatment is ineffective:

• Intranasal corticosteroids - to be used during periods of allergen exposure

Advise the person to be reviewed in 2-4 weeks if symptoms persist after initial treatment

Question 11

When would you refer patients with allergic rhinitis to ENT?

Answer 11

• Red flag features e.g. unilateral symptoms, blood-stained nasal discharge, recurrent nose bleed
• There is a nasal obstruction and structural abnormality e.g. deviated nasal septum which makes intranasal drug use difficult
• Persistent symptoms despite optimal management –> referral to allergic specialist
• Diagnosis is uncertain