Dr Lailyang Taniyang, MBBS, MS (ENT) Junior Consultant, Department of Ear, Nose and Throat, CIHSR 4th Mile Dimapur AACCHOOO!! Bokato blasted into a sneeze, making a frightening grimace and leaving everyone alarmed. He had seriously mistimed putting his damp hanky onto his mouth. Meanwhile a drizzle of his oronasal fluid came down on those nearby in a cool mist. Just as everyone regained their nerves, a minute later, AACChOO!! Bokato went again. And again. And again. If you experienced this symptom like Bokato before, you might have had a condition called Rhinitis. It is defined clinically by a combination of two or more symptoms of the nose: running, blocking, itching, and sneezing. When these symptoms occur due to exposure to an allergen, then it’s called Allergic Rhinitis. An allergen is anything that causes allergy, like dust, smoke, powder, pollen, animal fur or some food. When you get them during some particular months like winter, spring or rainy season then we call it Seasonal Allergic Rhinitis and when its present whole round the year then it is called Perennial Allergic Rhinitis. Rhinitis is more common in developed countries and increases in prevalence in the urbanized areas. Many possible factors have been suggested, such as lifestyle changes, increased exposure to allergen, pollution and irritants, dietary modifications responsible for diminution of protective nutrients, and decrease in infections due to ‘too much of hygiene’ which leads to decrease in immune response. This is called Hygiene hypothesis. It has also been found that early Nursery attendance (which involves mixing with other kids) and children who are exposed to pets early in their life are less likely to have allergy. (So a little bit of dirt might be actually good for your baby!) Immediate type allergic symptoms of sneezing, Running nose, and itch are easily recognised. However, perennial allergic inflammation may not have these acute symptoms and is mainly expressed as nasal obstruction, hyper-reactivity and often concomitant poor sense of smell. These patients are often not identified as allergic by themselves or by their doctors, and may undergo unnecessary operations before the true nature of their problem is revealed by adequate history taking, assessment of allergy by skin prick or blood testing. The presenting symptoms are very important in the diagnosis of allergic rhinitis. Also to be checked are other associated conditions like asthma, ear infections (ear pain and discharging ear), sleep disorders, lung infections etc. Rhinitis is a risk factor for development of asthma and also may cause exacerbation of asthmatic symptoms. So a proper treatment of rhinitis can reduce asthma symptoms. General medical history, past history and family history, occupational and environmental exposure, dietary history and drug use all need to be taken into account. The patient should always be asked which is his or her main symptom since treatment needs to be directed towards this. Patients more often than usual come to me with the complaint saying “Doctor, naak te dangor ekta mangso ulaiase, operation paribo naki?”(doctor, there’s a big mass inside my nose, is surgery possible for this?) which usually turns out to be the inferior turbinate, which is a normal part of the nose. This turbinate becomes swollen and edematous as a result of allergic response. The frequency, severity, duration, persistence, or seasonality of symptoms should be queried. Skin prick test (SPT) is an effective, cheap, and safe procedure to know what is causing the allergy. Here the skin pricks are given on the forearm and a plethora of possible allergens, like house dust mite, fur from cat, dog or grass pollen etc are applied to each prick and any reaction in the form of a wheal are noted. Reactions greater than 2 mm in under 5yrs and 3 mm in older subjects are regarded as positive. Other tests used for diagnosis are Radio allergosorbent test (RAST), Serum Immunoglobulin E level, Nasal allergen Challenge Etc. Medical treatment in allergic rhinitis includes antihistamines, steroid nasal sprays and nasal decongestants. Most of the medications are just for symptomatic relief and patient may experience resurgence of symptoms on re-exposure to the allergen or if he/she is suffering from a more long term condition. During symptomatic period patient can do saline nasal douching regularly (flushing the nose with warm salt water) as a home based treatment. This method clears out the dust and pollens from the nose and helps in relieving nasal stuffiness. Immunotherapy is a recent advancement in its management but is expensive. Allergen immunotherapy involves the repeated administration of an allergen extract in order to induce a state of immunological tolerance, with a reduction in clinical symptoms and requirements for medication during subsequent natural allergen exposure. Allergen immunotherapy is advised in those patients with allergic rhinitis with severe symptoms who fail to respond adequately to usual treatment with antihistamines and topical nasal corticosteroids. The primary management is to try avoid the allergen as far as possible. If you suffer from allergic rhinitis here are few tips to consider:
- Remove/Clean the things which might be a source of allergen in your home, like rugs, old dusty stuffed dolls, damp mattress, dusty fan blades and ceilings.
- encase mattress and pillows in plastic covers
- store clothing in drawers and remove unused clothing from the bedroom
- use washable curtains, clean every two weeks
- Keep your home dust free. Wet mopping is advisable rather than using the broomwhich might cause the dust to be airborne. Dust contains most of the allergens in your home.
- Try keeping pet animals only in certain areas of the home. You could build kennels for your dog or place rugs in the verandah for the cat.
- Avoid having moulds in the bathroom. Clean regularly.
- Avoid Smoking.
- Wood smoke, kerosene stove fumes, charcoal smoke, all are culprits.
- Be extra careful during Spring season when pollens are rampant.
- Use face masks when you go outside, especially if the weather is rainy, windy and dusty.
- Do not use fan with an open window, as this can bring more pollen into your home.
- Be careful when you do gardening, as you might expose yourself with molds and pollens.
Courtesy: Scott Brown’s Textbook of Otorhinolaryngology, Head and Neck Surgery. 7th Edition