Allergic Rhinitis in Otolaryngology and Facial Plastic Surgery Treatment & Management

Updated: Nov 14, 2017
  • Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Care

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 injections

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. [3]

Sublingual (SL) immunotherapy

SL immunotherapy may not be appropriate for everyone. Those affected by multiple allergens may not obtain relief of all of their symptoms by taking immunotherapy for only a single or several allergens. SL immunotherapy is more convenient in than weekly injections for individuals with limited, specific allergies that match the SL product.

In April 2014, the FDA approved an SL tablet consisting of 5 calibrated grass pollen extracts (Oralair). It contains Perennial Ryegrass (Lolium perenne), Kentucky bluegrass (Poa pratensis), Timothy grass (Phleum pratense), Orchard grass (Dactylis glomerata), and Sweet Vernal grass (Anthoxanthum odoratum). [4]

The Oralair SL tablet needs to be initiated 4 months prior to the season for the specific allergen.

A second SL immunotherapy for Timothy grass (Grastek) was also approved in April 2014 for adults and children aged 5 years or older. It should be initiated at least 12 weeks before the start of the grass pollen season. [5] Efficacy and safety in North America was established in a large study (n=1500) of adults and children aged 5-65 years. Results showed a 23% improvement of symptoms in the entire grass pollen season. [6]

A third SL immunotherapy for ragweed (Ragwitek) was also approved in April 2014 for adults aged 18 years or older. Effectiveness studies included about 760 patients. Phase 3 clinical trials showed reduced rhinoconjunctivitis symptoms over the entire season by 27-43% compared with placebo. It is approved for adults aged 18 years or older. [7, 8]

An SL immunotherapeutic agent (Odactra) for house dust mites was approved by the FDA in 2017 for adults aged 18 through 65 years. It is a standardized allergen extract indicated as daily SL immunotherapy for allergic rhinitis, with or without conjunctivitis, confirmed using in vitro testing for IgE antibodies to the house dust mite D farinae or D pteronyssinus, or through skin testing using licensed house dust mite allergen extracts. [9]

The first dose must be administered in a healthcare setting and supervised by a doctor experienced in allergic disease diagnosis and treatment. After this initial dose is given, the patient must be monitored for signs or symptoms of a severe systemic or local allergic reaction. Within the prescribing information, a boxed warning describes life-threatening allergic reactions. The boxed warning also specifies that the patient must be prescribed autoinjectable epinephrine to have while using house dust mite immunotherapy.

Approval was based on a double-blind, multicenter trial (n = 1482) in adolescents and adults with house dust mite allergic rhinitis with or without conjunctivitis (AR/C). Over a 52-week period, house dust mite immunotherapy improved the rhinoconjunctivitis score and visual analog scale–assessed AR/C symptoms. [10]

A study by Soh et al indicated that sublingual immunotherapy with extracts from the dust mite Blomia tropicalis is effective in treating allergic rhinitis sensitized to this species. The study, which included 39 children and adults, found patients’ Total Nasal Symptom Scores and Mini Rhinoconjunctivitis Quality of Life Questionnaire scores improved after 3 months of treatment and continued to approve thereafter. [11]

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Surgical Care

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. [12]

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Consultations

A pulmonologist may be consulted.

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Diet

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.

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Activity

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.

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