A 9-year-old girl presents to her pediatrician for constant nasal congestion, runny nose, and intermittent bouts of sneezing and itching. Her symptoms occur year-round with increased symptoms in the spring and fall. On examination she has dark circles under her eyes (“allergic shiners”; Figure 215-1), bilateral conjunctivitis (Figure 215-2), swollen, pale, inferior turbinates, and a copious clear watery nasal discharge (Figure 215-3). Over-the-counter antihistamines have helped minimally so she is given a prescription for a nasal steroid spray to use daily. This significantly improves but does not eliminate the symptoms. She is seen by an allergist who obtains a history that she sleeps on feather pillows, lives with two cats, and also has eye itching and redness when outside in the spring. Skin prick testing to local environmental allergens shows positive reactions to dust mites, cats, and grass and ragweed pollens (Figures 215-4 and 215-5). Recommendations for avoidance of the dust mites, cats, and the outdoor pollens were given. Her technique and adherence with the nasal steroids was discussed and she was given nasal antihistamines to treat breakthrough symptoms.

Allergic rhinitis is a syndrome of upper airway symptoms in patients who are sensitive to aeroallergens including but not limited to animal dander, dust mites, mold spores, pollen, cockroaches, and rodents. Many patients have a history of atopic dermatitis, allergic rhinitis and asthma that together make up the “atopic triad.” These symptoms may be present in a seasonal pattern or year-round with seasonal exacerbations.

Hay fever, Allergies, Pollinosis, the sniffles.

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  By 6 years of age, 42 percent of children will be diagnosed with allergic rhinitis by a physician.¹

  
  
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  Seasonal allergic rhinitis symptoms due to outdoor pollens rarely occur before the age of 2 years. However, sensitivity to indoor allergens can be present by the age of 1 year.

  
  
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  The prevalence of allergic rhinitis increases throughout childhood and adolescence.

  
  
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  Allergic rhinitis has been found in people from many different genetic backgrounds, but it tends to occur more often in people who have been raised in the urban/suburban areas of Westernized countries or in higher socioeconomic classes.²

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  Allergic rhinitis occurs in genetically predisposed individuals who are exposed to common aeroallergens.

  
  
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  The prevalence of allergic rhinitis and all atopic disease is much higher in people who are raised in more modern/western communities and occurs in all ethnic groups.

  
  
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  Most patients have a family history of atopic disease.

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  Genetically predisposed individuals can get allergic rhinitis symptoms when they are exposed to allergens, which float in the air, enter the nasal mucosa, and bind specific allergic antibodies called IgE.

  
  
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  When IgE recognizes an allergen, it leads to mast cell degranulation and intracellular signaling causing the cells to release preformed mediators such as histamine and start production of other inflammatory cytokines such as leukotrienes.

  
  
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  Histamine and other preformed mediators cause sneezing and itching.

  
  
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  Late phase inflammation leads to congestion and rhinorrhea.

  
  
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  Indoor allergens from cats, dogs, cockroaches, and dust mites are present year-round and lead to perennial allergic rhinitis.

  
  
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  Mold spores germinate when weather conditions are warm and wet.

  
  
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  Tree pollen, grass pollen, and weed pollen are produced by the 10 percent of plants, which use the wind to disperse their pollen. The pollen is released into the air when these plants flower, leading to seasonal allergic rhinitis.

  
  
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  Flowers, which are showy such as rose bushes, daisies, or cherry trees, do not cause allergic rhinitis as the pollen is too heavy to get into the nose or eyes. These flowers need the flowers to attract pollinators such as bees and insects to carry the pollen from one flower to the other.