....-ti-
`
`ANNALS -O F
`ALLERGY, ASTHMA,~
`~GJMMUNOLOGY
`
`November (Part II of 11), 1998
`Volume 81, Number 5
`
`Diagnosis and Management of Rhinitis:
`Parameter Documents
`of the
`Joint Task Force on Practice Parameters in
`Allergy, Asthma, and I mmunology
`
`Editors:
`Mark S Dykewicz, MD and Stanley Fineman, MD, MBA
`
`Chair, Workgroup on Rhinitis:
`David P Skoner, MD
`
`Associate Editors:
`Richard Nicklas, MD; Rufus Lee, MD; Joann Blessing-Moore, MD;
`James T Li, MD, PhD; I Leonard Bernstein, MD; William Berger, MD, MBA;
`Sheldon Spector, MD; and Diane Schuller, MD
`
`Official Publication of the American College of Allergy, Asthma & Immunology
`
`

`

`Diagnosis and Management of Rhinitis: Parameter Documents
`of the Joint Tas~ Force on Practice Parameters in Allergy,
`i:\sthma, and In1munology
`
`Editors
`Mark S Dykewicz, MD and Stanley Fineman, MD, MBA
`
`Chair, Workgroup on Rhinitis
`David P Skoner, MD
`
`Associate Editors
`Richard Nicklas, MD*; Rufus Lee, MD; Joann Blessing-Moore, MD;
`James T Li, MD, PhD; I Leonard Bernstein, MD; William Berger, MD, MBA;
`Sheldon Spector, MD; and Diane Schuller, MD
`
`These parameters were developed by the Joint Task Force on Practice Parameters in Allergy, Asthma and
`Immunology, representing the American Academy of Allergy, Asthma and Immunology (AAAAI), the American
`College of Allergy, Asthma and Immunology (ACAAI) and the Joint Council on Allergy, Asthma and Immunology.
`
`'
`
`1These parameters were developed with Dr. Nicklas in his private capacity and not in his capacity as a medical officer
`with the Food and Drug Administration. No official support or endorsement by the Food and Drug Administration
`is intended or should be inferred.
`
`The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy,
`Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing the statements in documents
`of these parameters. Because these documents incorporated the efforts of many participants, no single individual,
`including those who served on the Joint Task Force, is authorized to provided an official interpretation of these
`practice parameters· by the AAAAI or ACAAI. Any request for information about or an interpretation of these
`practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, ACAAI
`and the Joint Council on Allergy, Asthma and Immunology.
`
`Reprint requests to:
`Joint Council on Allergy, Asthma and Immunology
`50 N. Brockway St, Ste. 3-3
`Palatine, IL 60067
`
`

`

`A NALS OF
`ALLERGY, ASTHMA,~
`UNOLOGY
`I
`
`formerly published as ANNALS OF ALLERGY
`contents of ANNALS OF ALLERGY, ASTHMA, &
`IIVIMUNOLOGY Copyright© 1998 by the American
`college of Allergy, Asthma, & Immunology.
`
`Editor: Edward J O'Connell, MD
`Mayo Clinic
`411 Guggenheim Bldg
`200 First St SW
`Rochester, MN 55905
`507-538-0009
`
`The Annals of Allergy, Asthma, &
`Immunology is the Official Publication
`of the American College of Allergy,
`Asthma, & Immunology. It is published
`monthly by the American College of
`Allergy, Asthma, & Immunology
`November (Part II), 1998
`
`CONTENTS
`
`Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
`
`vi
`
`Executive Summary of Joint Task Force Practice Parameters on Diagnosis and Management of
`Rhinitis Mark S Dykewicz, MD and Stanley Fineman, MD, MBA.................................. 463
`
`Joint Task Force Algorithm and Annotations for Diagnosis and Management of Rhinitis
`Mark S Dykewicz, MD; Stanley Fineman, MD, MBA; Richard Nicklas, MD; Rufus Lee, MD;
`Joann Blessing-Moore, MD; James T Li, MD, PhD; I Leonard Bernstein, MD; William Berger, MD, MBA;
`Sheldon Spector, MD; and Diane Schuller, MD...... . .......... . . . ................................ 469
`
`Joint Task Force Summary Statements on Diagnosis and Management of Rhinitis
`Mark S. Dykewicz, MD; Stanley Fineman, MD, MBA; and David P Skoner, MD......... . .............. 474
`
`Diagnosis and Management of Rhinitis: Complete Guidelines of the Joint Task Force on Practice
`Parameters in Allergy, Asthma arid Immunology
`Mark S Dykewicz, MD and Stanley Fineman, MD, MBA, Editors
`David P Skoner, MD, Chair, Workgroup on Rhinitis
`Richard Nicklas, MD; Rufus Lee, MD; Joann Blessing-Moore, MD;
`James T Li, MD, PhD; I Leonard Bernstein, MD; William Berger, MD, MBA;
`Sheldon Spector, MD; and Diane Schuller, MD Associate Editors.............. . ..................... 478
`
`For submission of articles, see "Instructions for Authors"
`Changes of address directed
`to the ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
`should be sent to:
`Jim Slawny, Executive Director
`ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
`Suite 550, 85 West Algonquin Road, Arlington Heights
`Illinois 60005
`(847) 427-1200
`Telephone -
`email: annallergy@his.com
`
`Annals of Allergy, Asthma, & Immunology (ISSN-1081-
`1206) is published monthly for $50.00 (US), $75.00 (US
`institutions) and $78.00 (foreign) by the American Col(cid:173)
`lege of Allergy, Asthma, & Immunology, 7212 Davis Ct,
`Mclean, VA 22101. Periodicals postage paid at Mclean,
`VA and additional mailing offices. (POSTMASTER:
`Send address changes to AMERICAN COLLEGE OF
`IMMUNOLOGY, 85 West
`ALLERGY, ASTHMA, &
`Algonquin Road, Suite 550, Arlington Heights, IL 60005.)
`Printed in the USA.
`
`V
`
`

`

`Diagnosis and Management of Rhinitis:
`Complete Guidelines of the Joint Task Force
`on Practice Parameters in Allergy, Asthma
`and Immunology
`Mark S Dykewicz, MD,+ Stanley Fineman, MD, MBA,§ Editors
`David P Skoner, MD,C]I<J[ Chair, Workgroup on Rhinitis
`Richard Nicklas, MDII; Rufus Lee, MD; Joann Blessing-Moore, MD<J[; James T Li, MD, PhD**;
`I Leonard Bernstein, MDtt; William Berger, MD, MBA:j::j:; Sheldon Spector, MD§§; and
`Diane Schuller, MD,1111 Associate Editors
`
`This document contains complete guidelines for diagnosis and management of
`rhinitis developed by the Joint Task Force on Practice Parameters in Allergy,
`Asthma and Immunology, representing the American Academy of Allergy, Asthma
`and Immunology, the American College of Allergy, Asthma and Immunology and
`the Joint Council on Allergy, Asthma and Immunology. The guidelines are com(cid:173)
`prehensive and begin with statements on clinical characteristics and diagnosis of
`different forms of rhinitis (allergic, non-allergic, occupational rhinitis, hormonal
`rhinitis [pregnancy and hypothyroidism], drug-induced rhinitis, rhinitis from food
`ingestion), and other conditions that may be confused with rhinitis. Recommenda(cid:173)
`tions on patient evaluation discuss appropriate use of history, physical examination,
`and diagnostic testing, as well as unproven or inappropriate techniques that should
`not be used. Parameters on management include use of environmental control
`measures, pharmacologic therapy including recently introduced therapies and aller(cid:173)
`gen immunotherapy. Because of the risks to patients and society from sedation and·
`performance impairment caused by first generation antihistamines, second genera(cid:173)
`tion antihistamines that reduce or eliminate these side effects should usually be
`considered before first generation antihistamines for the treatment of allergic rhi(cid:173)
`nitis. The document emphasizes the importance of rhinitis management for co(cid:173)
`morbid conditions (asthma, sinusitis, otitis media). Guidelines are also presented on
`special considerations in patients subsets (children, the elderly, pregnancy, athletes
`and patients with rhinitis medicamentosa); and when consultation with an allergist- ·
`immunologist should be considered.
`
`Ann Allergy Asthma Immunol 1998;81:478-518.
`
`CONTRIBUTORS: Donald W Aaronson, MD;
`Allen D Adinoff, MD; James N Baraniuk, MD;
`Robert J Dockhorn, MD; William Dolen,
`MD; Howard M Druce, MD; Marianne Frieri,
`MD, PhD; Morton P Galina, MD; Leon Greos, MD;
`Alfredo A Jalowayski, PhD; Craig F La Force,
`MD; Eli O Meltzer, MD; Robert M Naclerio,
`MD; Keith M Phillips, MD; Gordon Raphael, MD;
`Michael Schatz, MD; Michael J Schumacher,
`MBBS; Howard J Schwartz, MD; Tommy C
`Sim, MD; Chester T Stafford, MD; William W
`Storms, MD; Michael J Tronolone, MD; Mi(cid:173)
`chael J Welch, MD; Chester C Wood, MD; and
`Robert S Zeiger, MD, PhD
`
`PRINCIPAL REVIEWERS: Jean A Chap(cid:173)
`man, MD; Robert A Nathan, MD; John Santilli,
`Jr, MD; Michael Schatz, MD; and Betty B Wray,
`MD
`This document was developed by the· Joint
`Task Force on Practice Parameters in Allergy;
`Asthma and Immunology,
`representing
`the
`American Academy of Allergy, Asthma and Im(cid:173)
`munology (AAAAI), the American College of
`Allergy, Asthma and Immunology (ACAAI) and
`the Joint Council on Allergy, Asthma and Im(cid:173)
`munology. The AAAAI and the AACAAI have
`jointly accepted responsibility for establishing
`these practice parameters. Because this docu-
`
`ment incorporated the efforts of many partici(cid:173)
`pants, no single individual, including those who
`served on the Joint Task Force, is authorized to
`provide an official interpretation of this docu(cid:173)
`ment by the AAAAI or ACAAI. Any request for
`information about or an interpretation of this
`document by the AAAAI or ACAAI should be
`directed to the Executive Offices of the AAAAI,
`ACAAI and the Joint Council on Allergy,
`Asthma and Immunology.
`* This parameter was developed with Dr.
`Nicklas in his private capacity and not in his
`capacity as a medical officer with the Food and
`Drug Administration. No official support or en(cid:173)
`dorsement by the Food and Drug Administration
`is intended or should be inferred.
`t Division of Allergy and Immunology. De(cid:173)
`partment of Internal Medicine, Saint Louis
`University School of Medicine, St. Louis, Mis(cid:173)
`souri; § Department of Pediatrics, Emory Uni(cid:173)
`versity School of Medicine, Atlanta, Georgia;
`'l['l[ Departments of Pediatrics & Otolaryngology,
`Children's Hospital of Pittsburgh, Uni,·ersity
`of Pittsburgh School of Medicine, Pittsburgh,
`II Department of Medicine,
`Pennsylvania;
`George Washington Medical Center, Washing(cid:173)
`ton, DC; 'l[ Departments of Medicine & Pediat(cid:173)
`rics, Stanford University Medical Center, Palo
`Alto, California; ** Department of Medicine,
`Mayo Clinic & Medical School, Rochester, Mm(cid:173)
`nesom; H Dcpanmenis of Medicine & Envi-ron(cid:173)
`menml Health, Univcr_sity of Cincinnati College_
`of Medicine, Cincinnati. Ohio; H DepJ11111cnt of
`Pediatrics. Divi. ion of Allergy and lmrnunn_l~gy,
`University of Califomi.1 College of Mc<l!c~n~
`Irvine, California; §§ Dcpnrtment nl' !vled1cmc.
`University of California-Los Angeles, Lo~ ~n(cid:173)
`gclcs. California: 1111 Oepartincnl of Pcdiumcs.
`Penn ylvnnin State University.
`l[ilton S. ~cr(cid:173)
`shey Medical Colleee, Hershey, Pennsyl\'anm.
`The Joinr Task Force has made :in int~se
`effort to :lppropri.ttcly :1cknowledge :ill .: nm~
`utors to this parameter. lf any contributn:• ~"
`inadvertently excluded. the Tnsk Force will 1~~
`sure t11ut appropriate recognition of such con1:11-
`butions is subsequently made.
`
`478
`
`ot
`ANNALS OF ALLERGY, ASTHMA, & TMMUNOLO
`
`

`

`--
`
`contents and Organization of this Document
`INTRODUCTION . ...... ....• . . . .... . . . ... • . .•. ..•....... . ....... . .. . .... . .. .. .. . . ... .
`DEFINITION OF RHINITIS . .... . ... . . . .. ... . ... .. ... .. ... . . . . .... . . . .. . . . ..... ....•....
`DIFFERENTIAL DIAGNOSIS OF RHINITIS ....... : ...... . ........ . . . .. . .... . .... .. .. . .. .. . . .
`Allergic Rhinitis . . .... . .... . .... . ... .. : . . .. . .. ... .. . . .. .. . .... . ... ... ... . .. ... . .. . .
`Non-Allergic rhinitis ... . ... ... ......... . ...... .. ........ .. ... .. . . . . .... ... . . ....... .
`Infectious rhinitis .. ... . ... ... ... . .... . ......... . .... . . . ...... .. ... ... ... . .. .. . . . .. .
`Non-Allergic rhinitis without eosinophilia .. ... . . .. . . ... . .. . .. .. . ...... . .. . .... .. .. . . •...•.
`Non-Allergic rhinitis with eosinophilia syndrome ... .. ........ . ......... . .... .. ... . . . .. . . ... .
`Occupational rhinitis ... . ..... ... ...... . ... . .. .. .... ... ....... . ......... .. . ••... . ...
`Hormonal rhinitis (pregnancy and hypothyroidism) . ... ... .. . . . .. .. .. ... ... . .... . ... . . .... . . .
`Drug-induced rhinitis ... . .. . .... . ....... .. ... . . . .. • . . . .. ...... . ..... . . . .. . . .........
`Rhinitis from food ingestion .. ... .. . .. . ...... . ... .. . . . ... ... . .... . . .. .. ... . .. • • ...... .
`Other conditions that may be confused with rhinitis .. ... . .......... . .. .. ... . .. . .. . . ... . . ... .
`Nasal polyps ........ .... .. . ... . .. .. ...... . .. .. . .. . . ... .. ... . . .... .. ... .. .. . .. . . . .
`EVALUATION OF RHINITIS ... ... ... .. .. . .... .. ..... . ...... .. ............ . ..... . .... . . .
`History .. . ..... . ..... ... . . .... . .. .... . . ... ... ... . . .. . ....... .. ... ... .. . • . ... ....
`Physical examination .. . . . .. .. ... . ... • ..• ... . ......... • ..................... • .• . . ... .
`Testing for specific lgE .. ... ... .. .. .. . . .... . .... . . . ... ... . . . . .. . . ... ... . . .. ........ .
`Special diagnostic techniques .. ... . .. . .. , ... . .................... . ...... . . . ... .. . . . •.
`Nasal cytology . . . . . . . . . . . . . . . . . . . . . . . . . . •. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . .. .
`Total serum lgE, blood eosinophil counts ... ......... . ..... . ... . .. . . . . .. . . .. .. . .. . ... . . . .
`. . .... ... ... . ... . .... .. ... . ..... . ... . .. . .... ... .. ... .
`Unproven or inappropriate testing
`. . . .. .. .. . ... . ... . .. . . . .... .. ... . .. .. .. ... . ...... . ..... • . .
`MANAGEMENT OF RHINITIS
`Environmental control measures .... .. ... . .... . .... . ... .. .............. . . . .. . . . . ... . .. .
`Pharmacologic therapy .. .. . . . ... .. .. .. .. .. .......... .. ... .. . ... ..... ..... . ........ .
`Antihistamines .. . . . . . .. .. .... . .. ... ......... . . . .. .. .. ... .. ... .. .. .. ... ... ...... .
`Issues with sedation/performance impairment ....... . ............ . . ...... . . . ... ... . .. . •
`Cardiac effects of some antihistamines .. ... . ... .. ... ... ... . .. .... ... .. . . . . . .... ... . .
`Intranasal antihistamines ................................. . ... . ...... . .... . . . . ... . .
`Oral and nasal decongestants .. . . . .. .. .. . . . ... . .. . . . .. . . . ... .. .... . . .. .. . .. .. .... .. .
`Nasal corticosteroids .......... . ............................................ . . ... .
`Oral and parenteral corticosteroids .. .. . . . .. .. ... . .... .. ... . . ...... .. ....... . •. . . .... .
`Intranasal cromolyn .. ......... . ......... . ........................ . ...... • . . . . . . . .
`Intranasal anti-cholinergics . . .... .. ... . .... . .... . .. . . . ... .. ... .. ... .. ....... ....•...
`Oral anti-leukotriene agents .. . .... .. . .... . . . .. . . . . . ...• .. . . . .... .... . .. . . . . . . . . . . ..
`Allergen immunotherapy ......... .. ... . ... .. ... .. ......... . .... . .... . . . . ..•.. .... . . .
`Surgical approaches for co-morbid conditions ....... ... ........ . .. . . ... . . . . . ....• . . . . . ... .
`Important considerations in management ... . ... . ... .. .... . ... .. ... .. .... . ... ... .. •. . • . . .
`Education of patient and caregivers . .. ....... . .. . ... . ..... . .. .. . ... ... .... ... ... .... .. .
`Importance of rhinitis management for concomitant asthma, sinusitis, and otitis media . .. .. . .. . . . .. .. .
`Special considerations in children, the elderly, pregnancy, athletes, and rhinitis medicamentosa .. .. . ... .
`Consultation with an allergist-immunologist . .... .. ... .. .. . ... . . ... . ...... .... ..... . . . . .. • .
`
`Summary
`Statement
`
`Page
`
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`13
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`25
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`
`VOLUME 81, NOVEMBER (PART Il), 1998
`
`479
`
`

`

`INTRODUCTION
`Rhinitis may be caused by allergic,
`non-allergic, infectious, hormonal, oc(cid:173)
`cupational and other factors. All too
`often, important causes of rhinitis go
`unrecognized by both physicians and
`patients. This leads to suboptimal con(cid:173)
`trol of the disease.
`Rhinitis is a significant cause of
`widespread morbidity.
`Although
`sometimes mistakenly viewed as a
`trivial disease, symptoms of rhinitis
`may significantly impact the patient's
`quality of life, by causing fatigue,
`headache, cognitive impairment and
`other systemic symptoms. Appropriate
`management of rhinitis may be an im(cid:173)
`portant component in effective man(cid:173)
`agement of co-existing or complicating
`respiratory conditions, such as asthma,
`sinusitis, or chronic otitis media. The
`cost of treating rhinitis and indirect
`costs related to loss of workplace pro(cid:173)
`ductivity resulting from the disease are
`substantial. The estimated cost of al(cid:173)
`lergic rhinitis based on direct and in(cid:173)
`direct costs is 2.7 billion dollars for the
`year 1995, exclusive of costs for asso(cid:173)
`ciated medical problems such as sinus(cid:173)
`itis and asthma. Allergic rhinitis, the
`most common form of rhinitis, affects
`20 to 40 million people in the United
`States annually, including 10% to 30%
`of adults and up to 40% of children.
`This document reviews clinically
`relevant information about pathogene(cid:173)
`sis and provides guidelines about diag(cid:173)
`nosis and management of rhinitis syn(cid:173)
`dromes. Throughout the document,
`summary statements that articulate key
`points precede supporting text and rel(cid:173)
`evant citations of evidence-based pub(cid:173)
`lications.
`
`DEFINITION OF RHINITIS
`1. Rhinitis is defined as inflamma(cid:173)
`tion of the membranes lining the
`nose, and is characterized by na(cid:173)
`sal congestion, rhinorrhea, sneez(cid:173)
`ing, itching of the nose and/or
`postnasal drainage.
`Rhinitis can be defined as a heteroge(cid:173)
`neous disorder characterized by one or
`more of the following nasal symptoms:
`sneezing, itching, rhinorrhea, and/or
`nasal congestion. Rhinitis frequently is
`
`accompanied by symptoms involving
`the eyes, ears, and throat. Post-nasal
`drainage may also be present fre(cid:173)
`quently.
`
`Reference
`1. Druce HM. Allergic and nonallergic
`rhinitis. In: Middleton EJ, Reed CE,
`Ellis EF, et al, eds. Allergy principles
`and practice, 5th edition. St. Louis:
`Mosby-Year Book
`Inc,
`1998:
`1005- 1016.
`
`DIFFERENTIAL DIAGNOSIS OF
`RHINITIS
`2. Rhinitis should be classified by
`etiology as allergic or nonaller(cid:173)
`gic.
`Allergic rhinitis is a very common
`cause of rhinitis. However, since ap(cid:173)
`proximately 50% of patients with rhi(cid:173)
`nitis do not have allergic rhinitis, other
`potential causes must also be ruled
`ou1. 1- 3 The following outline lists dif(cid:173)
`ferent forms of allergic and non-aller(cid:173)
`gic rhinitis, and conditions that may
`mimic rhinitis.
`I. Allergic rhinitis
`A. Seasonal
`B. Perennial
`C. Episodic
`D. Occupational (may also be non(cid:173)
`allergic)
`II. Non-allergic rhinitis
`A. Infectious
`1. Acute
`2. Chronic
`B. NARES syndrome
`(Nonallergic rhinitis with eo(cid:173)
`sinophilia syndrome)
`C. Perennial nonallergic rhinitis
`(Vasomotor rhinitis)
`D. Other rhinitis syndromes
`1. Ciliary dyskinesia syndrome
`2. Atrophic rhinitis
`3. Hormonally-induced
`A. Hypothyroidism
`B. Pregnancy
`C. Oral contraceptives
`D. Menstrual cycle
`4. Exercise
`5. Drug-Induced
`A. Rhinitis medicamentosa
`B. Oral contraceptives
`C. Anti-hypertensive
`apy
`
`ther(cid:173)
`
`D. Aspirin
`E. Nonsteroidal
`anti-in-
`flammatory drugs
`6. Reflex-Induced
`A. Gustatory rhinitis
`B. Chemical or irritant-in- ·
`duced
`C. Posture reflexes
`D. Nasal cycle
`E. Emotional factors
`7. Occupational (may be aller(cid:173)
`gic)
`III. Conditions that may mimic symp(cid:173)
`toms of rhinitis
`A. Structural/mechanical factors
`1. Deviated septum/septal wall
`anomalies
`2. Hypertrophic turbinates
`3. Adenoidal hypertrophy
`4. Foreign bodies
`5. Nasal tumors
`A. Benign
`B. Malignant
`6. Choanal atresia
`B. Inflammatory/immunologic
`1. Wegener's granulomatosis
`2. Sarcoidosis
`3. Midline granuloma
`4. Systemic lupus erythemato(cid:173)
`sus
`5. Sjogren's syndrome
`6. Nasal polyposis
`C . Cerebrospinal fluid rhin01Thca
`
`References
`1. Lieberman P. Rhinitis. In: Bone RC,
`ed. Current practice of medicine. vol 2.
`Philadelphia: Churchill Livingstone
`1996; VII:5.l-VIl:5.10.
`2. Mygind N, Anggard A, Drucc HM.
`Definition, classification, and termi(cid:173)
`nology [of rhinitis]. In: Mygind N,
`Weeke B, eds. Allergic and vasomotor
`rhinitis. Copenhagen, Munksgaard,
`1985;15.
`3. Sibbald B, Rink. E. Epidemiology of
`seasonal and perennial rhinitis: cLinical
`presentation and medical history. Tho(cid:173)
`rax 1991;46:895-901.
`
`Allergic Rhinitis
`3. Allergic rhinitis affects 20_ to
`40 million people in the United
`States annually including JO%
`to 30% of adult and up to ..iO%
`of children.
`
`480
`
`ANNALS OF ALLERGY, ASTHMA, & lMM
`
`01,0GY
`
`-
`
`

`

`4 The severity of allergic rhinitis
`· ranges from mild to seriously
`debilitating.
`5, The cost of treating allergic rhi(cid:173)
`nitis and indirect costs related to
`Joss of workplace productivity
`resulting from the disease are
`substantial. The estimated cost
`of allergic rhinitis based on di(cid:173)
`rect and indirect costs is 2.7 bil(cid:173)
`lion dollars for the year 1995,
`exclusive of costs for associated
`medical problems such as sinus(cid:173)
`itis and asthma. Rhinitis is also a
`significant cause of lost school
`days.
`6. Risk factors for allergic rhinitis
`include: (1) family history of
`atopy; (2) serum lgE > 100
`IU/mL before age 6; (3) higher
`socioeconomic class; (4) expo(cid:173)
`sure to indoor allergens such as
`animals and dust mites; (5) pres(cid:173)
`ence of a positive allergy skin
`prick test.
`Rhinitis is reported to be a very fre(cid:173)
`quent disease, although data regarding
`the true prevalence of rhinitis are dif(cid:173)
`ficult to interpret. Most population sur(cid:173)
`veys rely upon physician-diagnosed
`rhinitis for their data, and this may
`give rise to a much lower reporting of
`rhinitis. Some population studies have
`been done with questionnaires admin(cid:173)
`istered to the subjects followed in
`many cases by telephone interviews to
`try to make a specific diagnosis of
`rhinitis. These studies may reflect a
`more accurate prevalence of rhinitis
`but probably still underreport this dis(cid:173)
`ease.1-7
`Most epidemiologic studies have
`been directed towards seasonal allergic
`rhinitis, or hay fever, since this symp(cid:173)
`tom complex with its reproducible sea(cid:173)
`sonality is somewhat easier to identify
`in population surveys. Perennial aller(cid:173)
`gic rhinitis is more difficult to identify
`because its symptom complex may
`overlap with chronic sinusitis, recur(cid:173)
`rent upper respiratory infections, and
`vasomotor rhinitis.
`The prevalence of rhinitis in various
`epidemiologic studies ranges from 3%
`to 19%. Studies suggest that seasonal
`allergic rhinitis (hay fever) is found in
`
`approximately 10% to 20% of the pop(cid:173)
`ulation.2·8-10 One study showed a prev(cid:173)
`alence of physician-diagnosed allergic
`· 1'hinitis in 42% of 6-year-old children.3
`Overall, allergic rhinitis affects 20 to
`40. million individuals in the United
`States annually.11·12
`In childhood, males with allergic
`rhinitis outnumber females, but the
`gender ratio becomes approximately
`equal in adults and may even favor
`females. Surveys of medical students
`have resulted in a higher prevalence of
`rhinitis, but this may be related to the
`survey technique. 1·6·8
`Allergic rhinitis develops before age
`20 in 80% of cases. Studies have
`shown that the frequency of allergic
`rhinitis increases with age until adult(cid:173)
`hood and that positive immediate hy(cid:173)
`persensitivity skin tests are significant
`risk factors for the development of new
`symptoms of seasonal allergic rhini(cid:173)
`tis.1·8·13 There is a greater chance of a
`child developing allergic rhinitis if
`both parents have a history of atopy,
`than if only one parent is atopic. Chil(cid:173)
`dren in families with a bilateral family
`history of allergy generally develop
`symptoms before puberty; those with a
`unilateral family history tend to de(cid:173)
`velop their symptoms later in life or
`not at all.5·10
`There tends to be an increased prev(cid:173)
`alence of allergic rhinitis in higher so(cid:173)
`cioeconomic classes, in non-whites, in
`some polluted urban areas, and in in(cid:173)
`dividuals with a family history of al(cid:173)
`lergy. Allergic rhinitis is more likely in
`first-born children. Studies in children
`in the first years of life have shown
`that the risk of rhinitis was higher in
`those youngsters with early introduc(cid:173)
`tion of foods or formula, heavy mater(cid:173)
`nal cigarette smoking in the first year
`of life, exposure to indoor allergens
`such as animals and dust mite, higher
`serum IgE levels (> 100 IU/mL before
`age 6), and parental allergic disorders. 3
`Seasonal allergic rhinitis is appar(cid:173)
`ently becoming more common. One
`study showed that the prevalence of
`hay fever increased from 4% to 8% in
`the 10 years from 1971 to 1981.14 In
`another study, atopic skin test reactiv-
`
`ity increased from 39% to 50% in dur(cid:173)
`ing an 8-year period of evaluation. 15
`The impact on society is tremen(cid:173)
`dous. 16 The severity of allergic rhinitis
`ranges from mild to seriously debilitat(cid:173)
`ing. The cost of treating allergic rhini(cid:173)
`tis and indirect costs related to loss of
`workplace productivity resulting from
`the disease are substantial. The esti(cid:173)
`mated cost of allergic rhinitis based on
`direct and indirect costs is 2.7 billion
`dollars for the year 1995, exclusive of
`costs for associated medical problems
`such as sinusitis and asthma. The total
`direct and indirect cost estimates for
`allergic rhinitis have been reported to
`be $5.3 billion for 1996. This figure
`included the higher indirect costs asso(cid:173)
`ciated with increased loss of produc(cid:173)
`tivity, which, in turn, was related to
`extensive over-the-counter antihista(cid:173)
`mine use. Such treatment can cause
`drowsiness and impair cognitive and
`motor function (see summary state(cid:173)
`ment #34).
`Rhinitis is also a significant cause of
`lost school attendance, resulting in
`more than 2 million absent school days
`in the US annually. In children, there is
`evidence that symptoms of allergic rhi(cid:173)
`nitis can impair cognitive functioning,
`which can be further impaired by the
`use of first generation antihistamines.17
`
`References
`1. Hagy GW, Settipane GA. Prognosis of
`positive allergy skin tests in an asymp(cid:173)
`tomatic population. J Allergy 1971;48:
`200.
`2. Druce HM. Allergic and nonallergic
`rhinitis. In: Middleton EJ, Reed CE,
`Ellis EF, et al. Allergy principles and
`practice, 5th edition. St. Louis: Mosby(cid:173)
`Year Book Inc, 1998:1005-1016.
`3. Wright AL, Holberg CJ, Martinez FD,
`et al. Epidemiology of physician(cid:173)
`diagnosed allergic rhinitis in child(cid:173)
`hood. Pediatrics 1994;94(6):895-901.
`4. Aberg N, Engstrom I. Natural history
`of allergic diseases in children. Acta
`Pediatr Scan 1990;79:206-211.
`5. Aberg N, Engstrom I, Lindberg U. Al(cid:173)
`lergic diseases in Swedish school chil(cid:173)
`dren. Acta Paediatr Scan 1989;78:
`246 - 252.
`6. Fougard T. Allergy and allergy-like
`symptoms in 1,050 medical students.
`Allergy 1991;46:20- 26.
`
`VOLUME 81, NOVEMBER (PART II), 1998
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`481
`
`

`

`7. Aberg B, Hesselmar B, Eriksson B.
`Increase of asthma, allergic rhinitis
`and eczema in Swedish school chil(cid:173)
`dren between 1979 and 1991. Clin Exp
`Allergy 1995;25:815-819.
`8. Settipane RJ, Hagy GW, Settipane
`GA. Long-term risk factors for devel(cid:173)
`oping asthma and allergic rhinitis: a
`23-year follow~up study of college stu(cid:173)
`dents. Allergy Proc 1994;51:21-25.
`9. Varyonen E, Kalimo K, Lammintausta
`K. Prevalence of atopic disorders
`among adolescents in Turku, Finland.
`Allergy 1992;47:243-248.
`10. Smith JM. A five-year prospective sur(cid:173)
`vey of rural children with asthma and
`hay fever. J Allergy 1971;47:23-31.
`11. Fireman P. Allergic rhinitis. In: Fire(cid:173)
`man P, Slavin RG, eds. Atlas of aller(cid:173)
`gies. Philadelphia, PA: JB Lippincott,
`1991:9.2-9.18.
`12. McMenamin P. Costs of hay fever in
`the United States in 1990. Ann Allergy
`1994;73:35-39.
`13. Tang RB, Tsai LC, Hwang B, et al.
`The prevalence of allergic disease and
`IgE antibodies to house dust mite in
`school children in Taiwan. Clin Exp
`Allergy 1990;20:33-38.
`14. Linna 0, Kokkonen J, Lukin M. A
`10-year prognosis for childhood aller(cid:173)
`gic rhinitis. Acta Pediatr 1992;8 l:
`100-102.
`15. Sibbald B, Rink E, O'Souza M. Is the
`prevalence of atopy increasing? Br J
`Gen Pract 1990;40:338-340.
`16. Ross RN. The costs of allergic rhinitis.
`Am J Managed Care 1996;2:285-290.
`17. Vuurman EF, van Yegge! LM, Uiter(cid:173)
`wijk MM, et al. Seasonal allergic rhi(cid:173)
`nitis and antihistamine effects on chil(cid:173)
`dren's learning. Ann Allergy 1993;71:
`121-126.
`
`7. The symptoms of allergic rhinitis re(cid:173)
`sult from a complex allergen-driven
`mucosa]
`inflammation
`resulting
`from an interplay between resident
`and infiltrating inflammatory cells,
`and a number of inflammatory me(cid:173)
`diators and cytokines. Sensory nerve
`activation, plasma leakage and con(cid:173)
`gestion of venous sinusoids also con(cid:173)
`tribute.
`The nasal mucosa is designed to hu(cid:173)
`midify and clean inspired air. The ac(cid:173)
`tions of epithelium, vessels, glands,
`and nerves are carefully orchestrated to
`perform these functions. 1 Dysfunction
`of any of these structures may contrib-
`
`ute to the symptoms of allergic and
`nonallergic rhinitis. 2
`
`References
`1. Raphael GR, Baraniuk JN, Kaliner
`MA. How and why the nose runs. J
`Allergy Clin Immunol 1991;87:
`457-467.
`2. Baraniuk JN. Neural control of the up(cid:173)
`per respiratory tract. In: Kaliner MA,
`Barnes PJ, Kunkel GK, Baraniuk JN,
`eds. Neuropeptides in respiratory med(cid:173)
`icine. New York: Marcel Dekker, ·Inc
`1995;79-123.
`
`8. Allergic rhinitis may be character(cid:173)
`ized by early and late phase re(cid:173)
`sponses. Each type of response is
`characterized by sneezing, conges(cid:173)
`tion and rhinorrhea, but congestion
`predominates in the latter.
`Atopic subjects inherit the tendency to
`develop IgE-mast cell-TH2 lympho(cid:173)
`cyte immune responses. Exposure to
`low concentrations of dust mite fecal
`proteins, cockroach, cat, dog and other
`danders, pollen grains, or other aller(cid:173)
`gens for prolonged periods of time
`leads to the presentation of the allergen
`by antigen presenting cells (APC) to
`CD4+ lymphocytes that release IL3,
`IL4, IL5, GM-CSF and other cyto(cid:173)
`kines. These promote IgE production
`against these allergens by plasma cells,
`mast cell proliferation and infiltration
`of airway mucosa, and eosinophilia.
`Early or immediate allergic re(cid:173)
`sponse. With continued allergen expo(cid:173)
`sure, increasing numbers of IgE-coated
`mast cells move into the epithelium,
`recognize the mucosally-deposited al(cid:173)
`lergen, and degranulate. 1 Mast cell
`products include preformed mediators
`such as histamine, tryptase (a mast cell
`specific marker), chymase (in "con(cid:173)
`nective tissue" mast cells only), kini(cid:173)
`nogenase (generates bradykinin), hep(cid:173)
`arin, and other enzymes. Newly
`formed mediators include prostaglan(cid:173)
`din D2 and the cysteinyl-leukotrienes
`LTC4, LTD4, and LTE4 • These media(cid:173)
`tors stimulate vessels to leak and ·pro(cid:173)
`duce edema plus watery rhinorrhea;
`stimulate glands to exocytose their mu(cid:173)
`coglycoconjugates and antimicrobial
`substances; and dilate arteriole-venule
`anastomoses to cause sinusoidal filling
`
`and occlusion of nasal air passages.
`Sensory nerves are stimulated that con(cid:173)
`vey the sensations of nasal itch and
`congestion, and initiate systemic re(cid:173)
`flexes such as sneezing paroxysms.
`Release of these mast cell mediators ·
`and induction of these reactions occur
`within minutes of allergen exposure,
`and are termed the early or immediate
`allergic