Allergic Rhinitis in Otolaryngology and Facial Plastic Surgery Treatment & Management

The 3 basic approaches for the treatment of allergies are (1) avoidance, (2) pharmacotherapy, and (3) immunotherapy. Treatment should start with avoidance of allergens and environmental controls. In almost all cases, however, some pharmacotherapy is needed because the patient is either unwilling or unable to avoid allergens and to control the occasional exacerbations of symptoms. For patients with a severe allergy that is not responsive to environmental controls and pharmacotherapy or for those who do not wish to use medication for a lifetime, immunotherapy may be offered.

• Avoidance of allergens and environmental controls

  • Patients who have seasonal allergies should avoid outdoor activities when allergens are in the air. The patient's house and workplace should be kept as clean as possible.
  • House dust mites thrive in warm, humid conditions, and the antigen is found in their feces. Control measures include removing reservoirs (eg, stuffed animals, carpets, heavy drapes), covering bedding with dust-mite–proof covers, and washing potential reservoirs in hot water. Frequent vacuuming with a high-efficiency particulate-arresting (HEPA) vacuum and use of acaricides (eg, benzyl benzoate) and products that denature dust mite antigen (eg, tannic acid) are encouraged. In addition, lowering the relative humidity to less than 50% and lowering the temperature to less than 70°F are helpful in controlling the dust mite population.
  • If removing pets is not feasible, they should be kept at least out of the bedroom. Also, frequent vacuuming with an HEPA vacuum and washing the animals are helpful in decreasing the allergen load.
  • Molds are present throughout the year in damp areas, both indoors and outdoors. Attention should be paid to reservoirs such as refrigerator drip pans, areas around air conditioner condensers and under sinks, indoor plants, and decaying vegetation in the yard. The use of a dehumidifier and an HEPA air-filtration system is also encouraged.
• Immunotherapy

  • Immunotherapy is indicated for patients whose symptoms are not well controlled with avoidance measures and pharmacotherapy. It is also appropriate for those with symptoms lasting more than 1 season and documented allergen-specific IgE antibodies.
  • Immunotherapy should be considered only in individuals who can comply with weekly injections for approximately 3 years.
  • Immunotherapy should be avoided in those receiving beta-blockers and those who have poorly controlled asthma, autoimmune disorders, or immunodeficiency disorders.
  • During pregnancy, injections should not be initiated, and doses should not be increased.
  • Although the exact mechanisms of immunotherapy are not known, they are associated with decreased allergen-specific IgE levels and increased allergen-specific immunoglobulin G (IgG) levels. These IgG molecules are thought to be blocking antibodies that are important in impeding the allergic reaction.
  • Immunotherapy involves regular injections (every 5-7 d) of increasing amounts of each reacting allergen until the symptoms are relieved or the maximum tolerated dose is reached, at which time a maintenance dose is given every 2-4 weeks. This dose is maintained until symptoms are controlled for 2-3 seasons and then tapered.
  • Although systemic reactions are rare when immunotherapy is properly administered, only qualified personnel should give injections, and resuscitative equipment should be available.
  • A Cochrane Database of Systematic Reviews article concluded that the sublingual route is a safe and effective method of immunotherapy.^[2]

Although allergic rhinitis is a medical condition, adjunctive surgery may be offered to alleviate obstructive symptoms in appropriate individuals. Examples are nasal polypectomy in the patients who have severe polyposis and various inferior turbinate reduction maneuvers in patients who have nasal obstruction caused by turbinate hypertrophy that persists despite maximal medical therapy.^[3]

A pulmonologist may be consulted.

Food allergies can cause nasal symptoms similar to those caused by inhalant allergies. Therefore, a workup for possible food allergies should be considered if the patient has a history of food reactions, if findings of the inhalant allergy evaluation are negative, and if appropriate treatments fail to yield improvement.

In general, patients with allergies should avoid working and playing in areas that are known to exacerbate symptoms.

Outdoor activities should be restricted when the inciting allergens are in season.

Individuals who are sensitive to pollen should stay indoors in the morning, and patients who are allergic to molds should remain indoors in the early evening, because the allergens are more prevalent in the air at these times.