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FOUNDATION OVERVIEW

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Allergic rhinitis is a chronic inflammatory disease of the upper airways. It is characterized by one or more of the following symptoms: nasal congestion, rhinorrhea, sneezing, and itching. Allergic rhinitis can impact quality of life and can lead to sleep disturbance and missed work and school.

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Allergic nasal reactions are mediated by immunoglobulin E (IgE). Airborne allergens react with antigen-specific IgE bound to mast cells triggering a release of inflammatory mediators such as histamine and leukotrienes. Both early- (immediate) and late-phase allergic reactions occur following allergen exposure. Early-phase reactions happen within seconds to minutes and are due to the release of histamine, leukotrienes, tryptase, and cytokines. Sneezing, itching, rhinorrhea, and congestion are typical symptoms. The release of cytokines results in the infiltration of inflammatory cells such as basophils and eosinophils. This produces a late-phase reaction occurring 4 to 8 hours after allergen exposure. With continued exposure to the allergen, the late-phase inflammatory response results in chronic symptoms of allergic rhinitis.

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Patients with allergic rhinitis may present with the following symptoms: clear rhinorrhea, nasal congestion, allergic conjunctivitis, sneezing, postnasal drip, and itchiness in the nose, ears, and/or eyes. Allergic shiners (swelling and darkening of circles under the eyes due to nasal obstruction and venous congestion) and allergic salute (upward rubbing of the nose) are less reported signs.

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Allergic rhinitis can be differentiated from other types of rhinitis by a thorough history and physical examination. Chief concerns, symptoms, patterns, and triggers of nasal and related symptoms should be obtained from the patient. Percutaneous skin testing and allergen-specific IgE antibody testing (eg, radioallergosorbent test [RAST]) are the most common tests used to confirm the diagnosis of allergic rhinitis.

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Two classification schemes exist to grade the severity of allergic rhinitis. The Allergic Rhinitis and its Impact on Asthma (ARIA) organization has designated four categories of allergic rhinitis: mild intermittent, mild persistent, moderate to severe intermittent, and moderate to severe persistent. Patients who experience symptoms less than 4 days per week or for less than 4 consecutive weeks meet the criteria for intermittent allergic rhinitis. The persistent classification applies to patients whose allergic rhinitis symptoms occur more than 4 days per week and for more than 4 consecutive weeks. If symptoms do not impact daily activities, sleep patterns, work, or school, then the disease is considered mild. If these areas are impacted by allergic rhinitis, then the patient has a moderate to severe form. In a second classification scheme, the Joint Task Force on Practice Parameters categorizes allergic rhinitis as seasonal, perennial, or episodic. Seasonal allergic rhinitis refers to those patients with symptoms primarily during the spring and fall (high pollen seasons). Patients with perennial allergic rhinitis have symptoms throughout the year. Patients with episodic allergic rhinitis experience symptoms by sporadic exposures to inhalant aeroallergens.

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PREVENTION

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Patients should be advised to try and ...

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