Materials for this week:
- Case discussion
- Stuffy Nose Pediatrics in Review, Gargiulo and Spector, 2010
- Powerpoint shared by Dr. Abby Grant
Here are take-home points about evaluating stuffy nose/allergic rhinitis:
- How many people are affected by allergic rhinitis? Allergic rhinitis (AR) is considered among the most common chronic diseases in children, with a prevalence of up to 40%. As with other atopic disease, prevalence of AR has increased rapidly in the past 30 years. Children who have one form of atopy (allergic rhinitis, asthma, eczema) have a 3x greater risk of developing a second. The mean age of onset in one study was 10 years; by 6 years, 42% had been diagnosed with AR.
- What is the clinical definition or AR? Rhinitis is defined as “Inflammation of the membrane lining the nose, characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” AR is a hypersensitivity reaction to allergens due to IgE. Intermittent allergic rhinitis involves symptoms <4 days per week or for <4 weeks. Persistent symptoms occur >4 days per week for >4 weeks. It’s often tricky to evaluate relative to viral-induced symptoms, given there is so much frequency of both, but with AR, itching of nose and eyes is more prominent, rhinorrhea is clear.
- What do we see on physical exam? Nasal turbinates may appear edematous, with a pale to bluish hue. Cobblestoning from lymphoid hyperplasia may be seen on the posterior oropharynx. “Allergic shiners” are dark discolorations underneath the eyes due to venous engorgement and suborbital edema. Dennie-Morgan lines are folds under the eyes due to edema. The “allergic salute” is a transverse nasal crease in children who chronically push their palms upward under their noses (to wipe mucus)-(and they really happen – last year my daughter developed one of these!)
- What’s the appropriate work-up? You may decide to do skin testing to evaluate specific allergens and aid in environmental control strategies, such as for dust mites. Skin testing is preferred to blood testing, but is not 100% specific and requires clinical correlation with symptoms/triggers.
- How do we manage AR? Treatment options are allergen avoidance, pharmacotherapy, and immunotherapy (reserved for severe cases). Best medication class is intranasal steroids, which is approved for kids >2. Next best are non-sedating antihistamines (not as good at decreasing nasal congestion, specifically) or leukotriene receptor antagonists. Sometimes people develop tolerance to one group, so switching drugs can help. Decongestants are not recommended for young children due to side effects and rebound symptoms, and are only occasionally used in older children.