Allergic rhinitis (AR) is a common disease worldwide affecting 10-25% of the population and its prevalence is increasing. Hayfever caused by grass and tree pollen is the most common allergy that people experience.
Allergies to grass and tree pollen may now be cured by giving sublingual immunotherapy called GRAZAX. Grazax is taken as a tablet which dissolves under the tongue. In clinical trials, Grazax has been shown to produce a statistically significant reduction in symptoms compared to placebo.
This article on hayfever and hayfever treatment is written by Jaan Panesar, GMC Registered Specialist and ENT consultant surgeon at the Luton and Dunstable NHS Trust.
Allergic Rhinitis is defined as inflammation of the nose specifically caused by allergen exposure. Some of the specific allergies that cause inflammation inside the nose are house dust, air pollution, smoke, and grass and tree pollen. The allergens cause a change in the immune response of the nose and lungs by affecting the immunoglobulin called IgE. It is this IgE-mediated response that causes nasal stuffiness, runny nose, sneezing, itching and watery eyes.
To find out more about hayfever and GRAZAX, first find out if you suffer from allergic rhinitis.
Do you suffer from any of the following symptoms which are commonly associated with allergic rhinitis?
A runny nose, nasal blockage, nasal itching and sneezing?
The above symptoms are classically caused by allergic rhinitis including allergies to grass and tree pollen. Patients with rhinitis can be divided into two symptom complexes: ‘sneezers and runners’ or ‘blockers’. Those with allergic rhinitis are commonly ‘Sneezers and runners’. ‘Sneezers and runners’ have predominantly watery rhinorrhoea and variable nasal blockage. ‘Blockers’ have severe and constant nasal blockage.
Asthma or bronchial irritation?
A strong relationship exists between nasal allergies and asthma suggesting the concept of ‘one airway, one disease’. Allergies are responsible for asthma in some patients and may also cause making the asthma more difficult to control. Allergic rhinitis is therefore a risk factor for developing asthma or bronchial hyperactivity. About 30% of patients with rhinitis will go onto develop asthma.
Sinusitis or conjunctivitis?
These conditions often coexist with allergic rhinitis. The inflammation inside the nose causes swelling and blocks the drainage holes of the sinuses.
How severe are your symptoms?
Troublesome nasal symptoms can seriously impair your quality of life by affecting sleep and work.
Are you allergic to aspirin or brufen?
Aspirin or other nonsteroidal pain medication like brufen may bring on the symptoms of allergic rhinitis.
Is the problem unilateral or bilateral?
Tumours are rare but unilateral or one sided symptoms in association with facial swelling and bleeding from the nose are suspicious and should prompt immediate investigation.
Are there any pets in the house especially cats and dogs?
Your nasal symptoms may be due to or may be made worse by your pets. An allergy test will be able to confirm this.
Occupational rhinitis like occupational asthma can be brought on by certain occupations. Latex allergy is common in health care workers and industry workers. Bakers may develop allergies to flour.
What medications have you tried and for how long?
Over the counter nasal decongestants like vicks and otrovine often give instantaneous relief but paradoxically may make the nasal congestion worse if they are tried for long periods of time.
Is there a family history of allergy?
Allergies often run in families.
How is it diagnosed?
Skin prick tests: Immediate hypersensitivity skin tests are widely used to demonstrate an IgE-mediated allergic reaction. The test is painless and results are immediately available. If performed properly, they will demonstrate sensitivities to most common airborne allergens like hay fever. Common allergens that are tested for include house dust mite, pollen, and fungus, cat and dog dander.
Radioallergosorbent test (RAST): This is a blood test and serum specific IgE to different aeroallergens of. It is of similar value to skin prick tests and is done if skin prick tests are not available. RAST test may be done for food allergies.
Nasal and sinus examination: This is carried out with a specially designed flexible and rigid fiberoptic scope. By using the fiberoptic scope, the specialist will be able to determine if there is an infection or if there are polyps. Occasionally the septum or partition of the nose may be bent and this may need to be surgically corrected.
Eye examination: The eyes may be watery, puffy, red, itchy and tender.
Chest examination and peak flow spirometry: This is done if asthma is suspected or present.
Imaging: A CAT scan is the principal radiological investigation for disorders of the nose and sinuses. A CAT scan will demonstrate abnormal pathology in the sinuses like polyps. Occasionally an MRI scan may be needed.
What treatments will your doctor offer?
As an ENT Specialist, I would recommend that all treatments for allergic rhinitis are evidenced based and follow the world health organisation (WHO) guidelines.
For single allergies like grass and tree pollen: For hayfever sublingual immunotherapy like GRAZAX is very safe and effective. It offers an alternative to subcutaneous injection immunotherapy for grass pollen. It is taken as a pill four months before the hay fever season and is continued throughout the grass pollen season. Grazax should only be started by physicians with experience in the treatment of allergic disease.
For multiple allergies: The mainstay of treatment for multiple allergies as determined by the skin prick test or RAST blood test is a combination of oral antihistamines, intranasal steroids and oral steroids.
Mild symptoms can be managed by oral second-generation antihistamines. For moderate to severe symptoms, a combination of oral antihistamines and intranasal steroids are tried. In case of improvement, there is a step down of medication, in case of worsening there is a step up of medication. This is known as a stepwise treatment of allergic rhinitis and is one of the recommendation guidelines by the WHO. Medications have no long-lasting effect following discontinuation, therefore for persistent symptoms, maintenance therapy is required.
Please note: Depot steroid injections are no longer recommended due to side effects.
Nasal douching: This is a very important part of the treatment plan. Cleaning your nose with some natural salt preparation helps to clear the nasal passages by shifting the mucous in the nose.
Conjunctivitis is treated with an antihistamine.
Management of asthma: This is done with the help of a respiratory physician. If you suffer from asthma, you will find that proper control of nasal symptoms will improve the asthma symptoms.
Surgery: Functional endoscopic sinus surgery (FESS) to open the sinus drainage holes is done if sinusitis is suspected. Surgery to the side wall of the nose called inferior turbinate surgery or to the septum called Septoplasty may also be needed to improve the nasal airway. The surgery is carried out inside the nose. There are no external scars.
Education and allergen avoidance: Patients, who have confirmed allergies to house dust mite and fungus are encouraged to ventilate their rooms, use hypoallergenic pillows and duvets and mattress protectors. They should frequently change their bedding and vacuum their carpets. If possible, they should have laminate flooring in their bedroom.
Follow up is required for patients with persistent and severe symptoms.