Osmosis
A 6-year-old girl with increasing, bilateral nosebleeds over the past week (watch video)
Patient will present as → a 13-year-old boy with clear fluid discharge from his nose for 2 days duration. This has also been associated with sneezing. On nasal exam, the mucosa and turbinates appear edematous and slightly bluish, he has swollen dark circles under his eyes, and a transverse nasal crease.
Allergic rhinitis is an immunoglobulin E (IgE)– mediated reactivity to airborne antigens (e.g., pollen, molds, danders, dust). It commonly occurs in people who have other atopic diseases (e.g., asthma, eczema, atopic dermatitis) and those with a family history.
- Pt will present with boggy turbinates, allergic shiners (edematous, dark circles under eyes) and allergic salute: transverse nasal crease (from pushing up on the nose).
Diagnosis is by history and occasionally skin testing
Avoid any known allergens and use antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy
- Intranasal decongestants not to be used more than 3-5 days
- Rhinitis medicamentosa is caused by the overzealous use of decongestant drops or sprays containing oxymetazoline or phenylephrine. This causes a rebound congestion, which prompts increased use of the agent, creating a vicious cycle.
- To treat, discontinue the irritant. It may be quite uncomfortable for the patient; sometimes the use of topical corticosteroids is warranted through the withdrawal period
- Even “nonsedating” antihistamines have a to 15 percent sedation rate
Question 1 |
A 35 year-old patient has recurrent seasonal rhinitis and a history of mild asthma. Which of the following should be included for first-line management?
Immunotherapy Hint: Immunotherapy (desensitization) is indicated as a last resort in patients who fail to either respond to pharmaceutical management or face prolonged exposure to known allergens. | |
Decongestants Hint: Decongestants have a limited role in helping to decrease edema, and are generally ineffective in relieving allergic symptoms. | |
Corticosteroid inhalers | |
Cromolyn sodium (Intal) Hint: Cromolyn sodium has been found to be moderately effective for some patients with allergic symptoms, but it is not usually first-line management. |
Question 1 Explanation:
Regular use of corticosteroid nasal spray and oral inhalers prior to the allergy season is among the best means of preventing allergies.
Question 2 |
A 22 year-old woman presents with sneezing, runny nose, postnasal drip, and nasal congestion for the last week. She says this happens every spring. She is not allergic to any medications. Which of the following is the most appropriate pharmacologic treatment for this patient?
Azithromycin (Zithromax) Hint: Azithromycin is used to treat bacterial infections not allergic disorders. | |
Phenylephrine (Neo-synephrine) Hint: Neo-synephrine is not indicated in the treatment of allergic rhinitis. | |
Nedocromil | |
Pseudoephedrine Hint: Pseudoephedrine is a decongestant that may relieve the nasal congestion, but has no effect on the allergic response. |
Question 2 Explanation:
Nedocromil inhibits mast cell degranulation and is an effective treatment for allergic rhinitis. It may take 2-6 weeks for full therapeutic effect.
Question 3 |
A 9 year-old patient presents for follow up of his allergic rhinitis symptoms. He continues to complain of nasal congestion, sneezing, rhinorrhea, and eczema despite avoidance therapy and treatment with oral cetirizine (Zyrtec) and nasal flunisolide (Nasarel). Examination reveals pale, boggy nasal mucosa and eczema of the face and lower extremities. Which of the following is the most appropriate treatment at this time?
Ipratropium bromide Hint: Ipratropium bromide does not alleviate the sneezing and pruritus symptoms this patient is experiencing. | |
Montelukast Hint: Montelukast is less effective than intranasal steroids in the management of allergic rhinitis. | |
Immunotherapy | |
Cromolyn sodium Hint: Cromolyn sodium is much less potent than intranasal steroids and will likely not improve the patient's symptoms. |
Question 3 Explanation:
Immunotherapy is recommended in patients with severe allergic rhinitis who fail to respond to drug therapy and allergen avoidance. This patient has failed avoidance therapy, as well as antihistamines and intranasal corticosteroids.
Question 4 |
Which physical examination finding distinguishes allergic rhinitis from other rhinitis etiologies?
Clear rhinorrhea Hint: See D for explanation. | |
Erythematous pharynx Hint: See D for explanation. | |
Nasal flaring Hint: See D for explanation. | |
Pale nasal turbinates |
Question 4 Explanation:
On physical examination, the mucosa of the turbinates is usually pale or violaceous with allergic rhinitis because of venous engorgement in contrast to the erythema of viral rhinitis.
There are 4 questions to complete.
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