Pediatric Annals

Allergic Rhinitis

William A Howard, MD

Abstract

Allergic involvement of the nasal passages represents one of the most common of all allergic manifestations in childhood. The classic symptoms of nasal allergy include congestion, discharge, postnasal drip, sneezing and nasal obstruction manifestations that may mimic almost any pathologic process in the nose and that make differential diagnosis especially difficult (Table 1).

Allergic involvement of the nasal passages may take different forms.

1. Seasonal allergic rhinitis (hay fever)

2. Perennial nasal allergy.

3. Recurrent upper respiratory involvement of allergic origin.

SEASONAL ALLERGIC RHINITIS

This form of nasal allergy is generally due to pollens of grasses and trees in the spring, and to ragweed and other weeds in the late summer and fall. In some areas where molds are prevalent, there may be similar flares in the damp weather of spring and fall due entirely to mold. House-dust allergy may have similar seasonal flares that seem to coincide with the pollen seasons.

Typical hay fever is associated with fits of sneezing and marked rhinorrhea, with intermittent nasal obstruction. There is usually some itching of the eyes and tearing with conjunctival irritation and infection. Most annoying is the occurrence of intense itching of the palate and the area of the eustachian tubes. Symptoms are usually worse on arising and in the late afternoon and may be aggravated by infection, fatigue, and local irritations. Blowing the nose or rubbing the eyes may initiate intense itching, sneezing, and tearing.

Relief usually may be obtained with adequate doses of antihistamines or nasal decongestants. Responses to different classes of antihistamines may vary in any individual, and if adequate relief is not obtained from one antihistamine, a representative of a different class may be employed (Table 2).

Table

TABLE 1

NASAL PROBLEMS IN THE INFANT AND CHILD

TABLE 2

TREATMENT FOR SEASONAL ALLERGIC RHINITIS…

Allergic involvement of the nasal passages represents one of the most common of all allergic manifestations in childhood. The classic symptoms of nasal allergy include congestion, discharge, postnasal drip, sneezing and nasal obstruction manifestations that may mimic almost any pathologic process in the nose and that make differential diagnosis especially difficult (Table 1).

Allergic involvement of the nasal passages may take different forms.

1. Seasonal allergic rhinitis (hay fever)

2. Perennial nasal allergy.

3. Recurrent upper respiratory involvement of allergic origin.

SEASONAL ALLERGIC RHINITIS

This form of nasal allergy is generally due to pollens of grasses and trees in the spring, and to ragweed and other weeds in the late summer and fall. In some areas where molds are prevalent, there may be similar flares in the damp weather of spring and fall due entirely to mold. House-dust allergy may have similar seasonal flares that seem to coincide with the pollen seasons.

Typical hay fever is associated with fits of sneezing and marked rhinorrhea, with intermittent nasal obstruction. There is usually some itching of the eyes and tearing with conjunctival irritation and infection. Most annoying is the occurrence of intense itching of the palate and the area of the eustachian tubes. Symptoms are usually worse on arising and in the late afternoon and may be aggravated by infection, fatigue, and local irritations. Blowing the nose or rubbing the eyes may initiate intense itching, sneezing, and tearing.

Relief usually may be obtained with adequate doses of antihistamines or nasal decongestants. Responses to different classes of antihistamines may vary in any individual, and if adequate relief is not obtained from one antihistamine, a representative of a different class may be employed (Table 2).

Table

TABLE 1NASAL PROBLEMS IN THE INFANT AND CHILD

TABLE 1

NASAL PROBLEMS IN THE INFANT AND CHILD

At times conjunctival involvement may necessitate the use of some local medication. Astringent drops, usually containing zinc sulfate and either epinephrine or phenylephrine, may be of some help, but local steroids may be necessary at times. For the occasional child with severe symptoms who can master the technique, nasal insufflation of a steroid, such as dexamethasone (Decadron, Turbinaire), may be useful. In a rare instance, oral steroids may be required for a brief period.

Table

TABLE 2TREATMENT FOR SEASONAL ALLERGIC RHINITIS

TABLE 2

TREATMENT FOR SEASONAL ALLERGIC RHINITIS

Since it is difficult to avoid the causative agents, one may wish to consider the use of specific immunotherapy. The decision should be based on the duration and severity of the symptoms and the presence of such complications as bronchitis or asthma.

PERENNIAL ALLERGIC RHINITIS

This is one of the most annoying conditions in childhood, bothersome to both the child and his family. The nose is almost constantly blocked with swollen turbinates, and while there may be some irritating postnasal drip, there is rarely any runny nose. Blowing the nose is difficult if not impossible, and no mucus can be obtained. This is the child who is often accused of not knowing how to blow his nose. Snoring and mouth breathing are present, and there is often some night cough. There is some local itching of the nose, and the allergic "salute" is characteristic, in which the child rubs the tip of the nose upward with the palm of the hand, a very successful maneuver in alleviating the itching.

There is usually some periorbital edema, discoloration under the lower lid (allergic "shiner"), and a broadened appearance to the bridge of the nose. Because of mouth breathing and the effort of breathing through the obstructed nose, the nasolabial folds are deepened, the corners of the mouth droop, and there may be malocclusion with overbite, producing what is generally referred to as the "adenoid facies," though it is just as often due to nasal allergy. The effort required to breathe through the obstructed nose may also induce some changes in chest configuration, with some indentation at the insertion of the diaphragm and some xiphoid depression, reminiscent of the shape of the chest in some asthmatics.

These children receive minimal relief from symptomatic therapy. Antihistamines and decongestants offer little help, since they tend to dry the nasal mucosa even more, and topical application of nose drops and sprays offer only temporary relief, with the added complication of the "rebound" reaction. Occasional use of nose drops at bedtime will at least help the child to get to sleep and will lessen the problem of rebound. Local steroids may be needed, but there is the danger of overuse and potential side effects.

When allergy is the principal cause, significant help can be obtained by appropriate use of environmental control measures and employment of specific immunotherapy.

RECURRENT UPPER RESPIRATORY INVOLVEMENT OF ALLERGIC ORIGIN

These are the children who seem to suffer from repeated respiratory infections, mostly during the winter months. An attack is ushered in by sneezing and a runny nose, with clear mucoid discharge, which is generally followed by some degree of throat irritation and cough. If left untreated, the nasal discharge tends to become cloudy with the advent of secondary infection. Recovery will occur within seven to 10 days, only to be followed in two to three weeks by a similar episode.

Recognition of the allergic nature of these bouts will lead to appropriate management with antihistamines used at the onset of the attack.

As in perennial allergic rhinitis, eventual relief will require careful attention to environmental factors, and since indoor allergens are likely to be a major consideration, immunotherapy may be helpful.

It may be difficult at times to separate completely the three forms of allergic nasal involvement, and there may be considerable overlap. For this reason and because most children tend to have multiple sensitivities, the perennial type of immunotherapy is generally recommended. Coseasonal treatment, giving gradually increasing doses of a single antigen several times weekly, may be employed when the child is seen first at the beginning of a pollen season and is not responding to medication. Preseasonal treatment is rarely recommended for children.

TABLE 1

NASAL PROBLEMS IN THE INFANT AND CHILD

TABLE 2

TREATMENT FOR SEASONAL ALLERGIC RHINITIS

10.3928/0090-4481-19790901-05

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