Best Dx/Best Rx: Allergic Rhinitis and Chronic Sinusitis

Allergic Rhinitis

Raymond G. Slavin, M.D.
St. Louis University School of Medicine

Allergic inflammatory response in the nose, seasonal or perennial.

Key Clinical Features

Paroxysms of sneezing
Nasal congestion
Clear rhinorrhea
Itching of nose and palate
Possible signs
- Mouth breathing
- Dark under-eye rings (allergic shiners)
- Allergic crease on bridge of nose
- Mucosal edema

Differential Diagnosis

Viral URI
Perennial nonallergic rhinitis (i.e., symptoms precipitated by temperature, humidity, and barometric pressure changes; strong odors; alcohol; cigarette smoke)

Best Tests

History of repetitive sneezing, rhinorrhea, nasal itching sufficient for diagnosis in most patients
Skin testing: start with epicutaneous testing: if results are negative but symptoms strongly suggest allergy, perform intradermal testing (higher sensitivity, lower specificity than epicutaneous); patients should discontinue antihistamines (but not corticosteroids) 1 wk before skin testing
Nasal smear showing preponderance of eosinophils

Best Therapy

Environmental control: minimize allergens (e.g., using air conditioning, removing dust mites and pet dander)
Pharmacotherapy
- Antihistamines: second-generation antihistamines less sedating than older ones; intranasal spray (azelastine) also efficacious
  - Cetirizine: first choice
    - Dose: 10 mg once a day
    - Cost/mo: $58.99
  - Fexofenadine: first choice
    - Dose: 60 mg b.i.d. or 180 mg q.d.
    - Cost/mo: $79.99
  - Loratadine: second choice
    - Dose: 10 mg q.d.
    - Cost/mo: $26.99
  - Azelastine:
    - Dose: 1 puff each nostril b.i.d.
    - Cost/mo: 34 ml, $57.99
- Over-the-counter antihistamine-decongestant combinations: may be sufficient for mild symptoms
- Inhaled corticosteroids: most effective but may have local side effects (e.g., irritation)

Budesonide: first choice
- Dose: 1 puff each nostril q.d.
- Cost/mo: 200 μg/inhalation, $122.99
Flunisolide: first choice
- Dose: 2 puffs each nostril q.d.
- Cost/mo: 7 g inhaler, $66.99
Fluticasone: first choice
- Dose: 2 puffs each nostril q.d.
- Cost/mo: 13 g inhaler, $52.99
Mometasone: first choice
- Dose: 2 puffs each nostril q.d.
- Cost/mo: 17 g inhaler, $63.99
Triamcinolone: first choice
- Dose: 2 puffs each nostril b.i.d.
- Cost/mo: $20 g inhaler, $63.99
Beclomethasone: second choice
- Dose: 2 puffs each nostril q.d.
- Cost/mo: 25 g inhaler, $56.99

Immunotherapy: for patients with severe symptoms not controlled by other treatments

Best References

Corren: J Allergy Clin Immunol 105:S610, 2000

Dykewicz: J Allergy Clin Immunol 111:S520, 2003

Jen, et al: J Allergy Clin Immunol 105:732, 2000

Kaszuba, et al: Arch Intern Med 161:2581, 2001

July 2004

Chronic Sinusitis

Raymond G. Slavin, M.D.
St. Louis University School of Medicine

Chronic inflammation in nares and sinuses due to the following
- Irritants
- Allergens
- Microbial pathogens

Key Clinical Features

Differential Diagnosis

Best Tests

Nasal smear shows sheets of PMNs and bacteria
Otolaryngologist may perform antral puncture when determination of pathogen necessary (e.g., suspect fungal infection)
If diagnosis in doubt, refer patient to otolaryngologist for fiberoptic nasopharyngoscopy for better visualization of drainage ostia
Radiologic studies essential for the following cases
- Severe
- Refractory
- Nosocomial
- Complicated

Best Therapy

Pharmacologic Therapy

Nonpharmacologic Therapy

Best References

Hamilos: Allergy Clin Immunol 106:213, 2000

Kaliner: Am J Med Sci 316:21, 1998

Snow, et al: Ann Intern Med 134:487, 2001

July 2004