Vincent Cumberworth BSc FRCS Consultant Ear, Nose and Throat Surgeon
Clementine Churchill Hospital Sudbury Hill Harrow Middlesex HA1 3RX
Private Secretary: Tel: 020 8872 3866 Fax: 0208872 3861

Information is supplied only upon the condition that the viewer will make their own determination as to the suitability of the information for its purposes prior to use.  There will be no responsibility for information that is misused or misinterpreted and the information should not be used as a substitute for consultation with a health care professional.  It is not possible to answer questions regarding individual cases or to enter into individual correspondence.

Allergic Rhinitis

Allergic Rhinitis

Allergic rhinitis is characterised by attacks of nasal blockage, with sneezing and rhinorrhoea.  It may be seasonal (“hay fever”), when responsible allergens can include grass and tree pollen or perennial, when house dust mite and animal fur may be a factor.

The lining of the nose swells on contact with the responsible allergen and there is increased production of mucus.  This leads to increased discharge and blockage, leading to facial symptoms such as headache and discomfort and there may also be a watery discharge from the eyes

If it is possible to identify the responsible allergen then avoidance can be possible.  Rarely, desensitisation may be considered but this is no longer a first line treatment due to risk of anaphylaxis – a potentially severe and dangerous allergic reaction.
Review by a GP or ENT Surgeon may be necessary and sometimes skin or blood testing can be performed to identify an allergen.

Nasal sprays, often involving topical steroids, can be beneficial; antihistamines can be used, either topically or systemically, to reduce the symptoms.

As well as the specific areas outlined above, avoidance of smoky environments and air pollutants can also be beneficial. Hay-fever is the common name given to cold-like symptoms caused by inhalation of plant pollen, which produces inflammation and swelling of the lining of the airway.  Inflammation of the lining inside the nose is called rhinitis and Hay-fever is termed Seasonal Allergic Rhinitis.  It occurs at particular times of the year when the various plants release their pollen.

Hay Fever

Hay-fever affects one in four people in the UK and approximately nine out of ten hay-fever sufferers will be allergic to grass pollen, with symptoms between May and July.  Trees release their pollen in the air during springtime between February and May and therefore cause an earlier onset of symptoms. Approximately half of UK hay-fever sufferers have a tree pollen allergy. Some individuals are allergic to both tree and grass pollen and will have symptoms that last for several months of the year.

Plants only disperse their pollen during their growing season and therefore individual plant pollen is not in the air all year round; they release their pollen at the same time every year, when the weather is dry. Wet weather conditions will influence pollen dispersal and will affect how long it remains in the air. Throughout the pollen season, specialist pollen monitoring centres trap pollen and calculate the daily concentration of the various airborne pollens. The daily pollen count is broadcast by media outlets, along with the weather forecast and is reported as low, medium or high. Highly sensitive individuals can suffer hay-fever symptoms even when the pollen count is low. When the pollen count is high, most people sensitised to the pollen are likely to have symptoms.

Symptoms of hay-fever can include:

  • Itchy nose, with or without itchy ears, throat, and eyes
  • Sneezing
  • Watery discharge from the nose and sometimes eyes
  • Blocked nose

Some sufferers who are allergic to tree pollen also experience irritation in the throat when eating certain raw fruit and vegetables, such as apples and celery. This is due to a cross reaction with pollen and is referred to as oral allergy syndrome.

Some hay-fever sufferers have poor quality sleep, reduced ability to concentrate and function less effectively at work or at school. Examination performance is reduced especially if the sufferers are on sedating antihistamine medication.

Some patients are so severely affected that they cannot go outdoors during the pollen season.

Rarely, the allergy can be so severe that a dangerous Type 1 Hypersensitivity reaction can occur with widespread manifestation including respiratory problems.

The regular seasonal pattern if symptom often allows self-diagnosis. For some people, however, symptoms may be less defined or even persistent for several months, and therefore allergy testing may be required.

A skin prick test may be carried out by placing a small drop of fluid containing an allergen on the skin. The skin is then pricked through the liquid. If a person is sensitised to the allergen the body releases histamine at the site of the prick causing a red swelling to occur. This reaction indicates that a person is likely to have symptoms of allergy to that particular allergen.

Serum allergy tests are also helpful, especially those for who skin prick tests are not possible, including people with severe eczema or very sensitive skin and those who cannot stop taking their antihistamine medication because of troublesome symptoms. Some people with positive allergy test have minimal hay-fever symptoms.

Management of hay-fever

1. Avoiding exposure to pollen in the air

  • Be aware of the pollen count
  • Avoid the countryside when the pollen count is high
  • Keep windows shut when travelling in a car and ensure the car has a pollen filter
  • Avoid being outdoors at times when the pollen count is high, such as when the air is warming in the mornings and cooling in the evenings
  • Keep bedroom windows closed early morning and evening when the pollen concentration is high
  • Hide pillows under the bed covers during the day to prevent pollen from settling when windows are open
  • Wear glasses to protect eyes from pollen when outside
  • Wash face and hair and change clothes when coming indoors on days when the pollen count is high
  • Wipe Vaseline around nose and eyes to trap pollen and prevent some from entering nose and eyes
  • Consider using a nasal air filter—www.nasalairfilter.com

2. Medication

For many people, hay-fever symptoms can be controlled with over the counter medication: saline sprays/douches, steroid nose sprays, antihistamine tablets/syrup/nose sprays, and eye drops. A pharmacist may offer helpful advice

Over the counter medications:

SYMPTOM MEDICATION EXAMPLE
Blocked nose Steroidal nasal spray are the most effective treatment for all nasal symptoms. They can  be used together with eye drops and antihistamine medication. Steroid nasal spray. E.g.Fluticasone orBeclometasone.
Itchy eyesWatery eyes – Eye drops- Chromone eye       drops- Antihistamine tablets/syrups or eye drops Eye drops. E.g. SodiumCromolglycateOral tablets/syrups. E.g. Loratadine or Cetirizine
Itchy noseRunny nose Antihistamine tablets/syrups or nasal sprays Oral tablets or syrups.- E.g. Loratadine or Cetirizine and or nasal spray.- E.g. Azelastine

Nasal decongestant sprays can be used for up to five days only occasionally, but never regularly, because they cause rebound congestion (“rhinitis medicamentosa”) which causes long-term swelling inside the nose, principally of the turbinates, persisting when the spray is no longer used and which can be very problematic to treat.  Essentially the pre-capillary sphincters in the erectile vascular tissue of the turbinates of the nose lose their resting tone – and any responsiveness to the “sympatheticomimetic” agents present in these decongestant sprays – to produce a degree of blockage greater than was originally present prior to treatment, which no longer responds to these agents and which is difficult to cure surgically.  Any operative procedures are difficult due to an even greater than usual propensity to bleed!

Steroid nasal spray treatment works best when started prior to the onset of symptoms, early in the hay-fever season.

Antihistamine medication will reduce symptoms or irritation but may be less effective at reducing nasal blockage.  Typically it can be taken as a tablet or syrup for children and also as nasal sprays and eye drops. One dose usually works within 30 minutes and therefore if symptoms are mild, or intermittent, it can be taken ‘as required’.  Continuous symptoms may require daily medication.

Chlorphenamine (such as Piriton) is effective but is required every four to six hours and may cause drowsiness, so should not be taken if driving or operating machinery. Some find sedating antihistamines useful when taken at night to reduce irritant symptoms and help sleep. Non-sedating (or, at least, less sedating) once-daily antihistamines, such as Loratadine or Cetirizine, may be preferable for some.  Alternatively, prescription medication may be necessary.

Homeopathy treatments, herbal remedies, nasal creams and powder sprays are also available, but not all have a proven scientific basis.

Short courses of oral steroids are occasionally prescribed.

3. Disease altering immunotherapy

Immunotherapy or ‘desensitization’ can reduce allergy to pollen and therefore a reduction in hay-fever symptoms. It is performed by a series of injections or by daily medication under the tongue (sublingual immunotherapy) in increasing quantities. The relief of the symptoms continues after the treatment is finished.

Immunotherapy is used mainly for patients whose symptoms are severe and not helped by other treatments. It should start before the pollen season begins and continue for 3 years. Most patients will have some reduction in allergy symptoms from the first year onwards. There is evidence that immunotherapy also reduces the progression of rhinitis to asthma in some patients.

Monitoring

A yearly review is advisable, particularly in children, which should include growth assessment where steroid treatments are used regularly.  An annual review before the pollen season starts allows early and therefore more effective prescriptions, before the airborne pollen causes troublesome symptoms.

House Dust Mite

House dust mites live on human skin scales and moulds wherever these can collect.  They specially favour mattresses, feather pillows, thick carpets and old soft articles, such as toys.  They can breed only at over 50% humidity and they prefer a temperature of around 25C.  What enters our airways is not the mite itself but its faecal pellets, which are light enough to enter the airways.

Regular cleaning of bedrooms and avoidance of materials particularly likely to collect dust are worthwhile measures to decrease the allergenic load.

Mites prefer to live in natural fibres.  Artificial fibres should be used for all bedding, (especially the duvet), carpet and curtains in the bedroom.  It is best to avoid Venetian blinds and padded headboards – these are a perfect home for mites!  Useful avoidance measures include:

  1. Weekly thorough vacuuming of the mattress, pillows, and around the base of the bed, with particular attention paid to around the buttons, where the mites are likely to live.
    Unfortunately, household vacuum cleaners can leak dust back into the atmosphere and allow mites to migrate back into the furnishings.  A disposable bag should be used, removed immediately after use and disposed of  in an outside bin.
    There are air cleaners and filters available which can remove airborne dust particles.
    Washing bed clothes at a high temperature (60C) may be beneficial.
  1. Air conditioners can prevent the high heat and humidity which permits mite growth.  Special filters can be added to help trap the airborne allergens.
  2. Ionisers can improve the quality of indoor air by restoring the balance of negative ions and removing dust, pollen and smoke from the atmosphere.
  3. Enclosing the pillows and mattress in either a plastic cover or specially made bedding forms a protective – ideally, allergen proof – barrier.
  4. Weekly thorough wiping of all household surfaces including tops of pelmets and door frames, skirting boards etc. with a damp duster (to avoid spreading the dust) is helpful.  Curtains and soft toys should be washed regularly in a machine.  Particular attention should be directed at removal of dust from upholstered furniture, vacuuming at least twice weekly, especially the headrest, arms and edges of the seats.  If curtains are present, regular cleaning or washing may help; blinds need to be dusted or vacuumed.  Soft toys should be removed, if possible.  Alternatively, I have been advised that freezing them in a sealed plastic bag may reduce house dust mites!
  1. Hard flooring also needs regular attention.

While these measures will not eliminate the House Dust Mite, they will reduce exposure to the type of dust which causes problems.

Tree and Grass Pollen

Pollens from different plants vary with the season and time of year.

Tree Pollens  March-April
Grass Pollen   May-July
Peak in June and July
Weed Pollen  : June-August
Mould Spores : September-October

  1. Check press for high pollen counts.
  2. Keep windows shut in cars and offices.
  3. Beware that pollen is highest in the early morning and early evening.
  4. Avoid open grassy places.

Cat and Dog Dander

It can be difficult to remove a pet from the home and protein from saliva can remain in a house for many months.

  1. Attempt restriction of pets to certain parts of the rooms and completely avoid bedrooms.
  2. Consider washing them!
  3. Again, it is easier to remove allergens from wooden and lino floors than the carpets.

Application of Nasal Drops

It is easier to put drops into the nose with the head tilted back but if it is possible to insert them with the head tilted forward then they coat the important physiological areas at the top of the nose.  If inserted with the head back ultimately they tend to run down the back of the throat and may avoid the higher areas of drainage in the nose.  Even if some drops run out from a head forward insertion, it is likely that they will have bathed the relevant areas first.

Three ways in which this can be achieved are:

  1. Lying face down across the edge of a bed with the head hanging downwards.
  2. Curling up in the “Mecca” position on the floor so that your head is upside down.
  3. Lying on your back with your head hanging back almost vertically so that the drops will run along the upper part of the nose on their way in rather than the floor of the nose.