Allergic Rhinitis
Chronic
Sinusitis
Allergic Rhinitis
Raymond G. Slavin,
M.D.
St. Louis University
School of Medicine
Definition/Key
Clinical Features
Differential
Diagnosis
Best
Tests
Best
Therapy
Best
References
Definition
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
Definition/Key
Clinical Features
Differential
Diagnosis
Best
Tests
Best
Therapy
Best
References
Definition
- Chronic inflammation in nares and sinuses due to the
following
- Irritants
- Allergens
- Microbial pathogens
Key Clinical Features
- Persistent sinus inflammation of > 8–12 wk
duration
- Purulent nasal and postnasal secretions
- Dull pressure in face or head
- Persistent, sometimes unilateral nasal stuffiness
- Hyposmia
- Fetid breath
- Malaise
- Increasing postnasal drainage with resultant cough
- Wheezing
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
- Use intranasal corticosteroids along with antibiotics
for at least 2 wk
- Amoxicillin
- Dose: 500 mg b.i.d.
- Cost/mo: $17.98
- Amoxicillin with clavulanic acid
- For penicillin-resistant sinusitis
- Efficacy, good
- Dose: 875 mg b.i.d.
- Cost/mo: $214.98
- TMP-SMX
- Alternative for patients with penicillin
sensitivity
- Efficacy, good
- Dose: 800/160 mg b.i.d.
- Cost/mo: $23.98
- Levofloxacin
- For penicillin-resistant sinusitis
- Efficacy, good
- Dose: 500 mg q.d.
- Cost/mo: $253.98
Nonpharmacologic Therapy
- Functional endoscopic sinus surgery
- For some cases of chronic resistant sinusitis
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
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