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Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
Allergic  Rhinitis
What is Allergic Rhinitis (AR)?: Commonly   called   hay   fever ,   AR   is   an   inflammation   of   the   inner lining     of     the     nose     that     occurs     when     an     allergic     individual encounters   an   airborne   allergen   such   as   house   dust   mites   (HDM) , pollen, mold, or animal dander like dogs and cats. Usually   inhaled,   these   triggers   generate   allergy   symptoms   such   as sneezing,   coughing,   runny   nose,   sore   throat   and   itchy   or   watery eyes,    phlegm    dripping    into    the    throat    (postnasal    drip),    chronic cough   and   puffy/red   itchy   eyes. Those   with   positive   family   history   of allergy   or   other   forms   of   allergy   eg.   bronchial   asthma,   eczema, urticaria   are   also   more   likely   to   have AR. Although AR   can   develop at any age, it usually appears in individuals before the age of 30. What are the other causes for the symptoms ? There   are   other   types   of   rhinitis   that   should   not   be   confused   with AR. All   types   of   rhinitis   affect nasal   and   sinus   function.   However,   many   other   types   of   rhinitis   respond   to   different   triggers   but may   present   quite   similarly   to   AR.   These   fall   into   a   general   category   of   non-allergic   rhinitis (NAR) . Causes may include: Infection, such as the flu or common cold Nasal polyps (frequently present in AR patients) Hormonal imbalance eg. pregnancy Overuse of decongestant nasal sprays Use of certain medications (aspirin, antihypertensives, some painkillers, oral contraceptives) Exposure to cold temperatures, high humidity, chemicals or other irritants Eating spicy or hot temperature foods However,   nasal   obstruction    can   also   be   due   to   structural   problems   within   the   nose   eg.   enlarged   nasal   turbinates or   deviation   of   the   nasal   septum   (DNS).   Also,   symptoms   of   nasal   allergies   must   also   be   differentiated   from cold/influenza   and   sinusitis.   If   blood   is   present   in   the   nasal   discharge,   it   is   imperative to   exclude   cancerous   growth   in   the   nasal   passage.   Therefore   the   role   of   the   ENT doctor   is   to   distinguish   between   the   different   possible   causes   from   history,   clinical examination    and    endoscopy.    Blood    investigation    (allergy    panel    and    IgE    test)    to identify the allergic triggers can be very helpful What are the complications of AR? Uncontrolled,   AR   can   seriously   impair   quality   of   life.   It   can   lead   to   snoring   and   may interfere     with     sleep     ( obstructive     sleep     apnea     OSA ),     resulting     in     daytime sleepiness, and affect the ability to learn and perform tasks. In    addition,    untreated    or    improperly    treated   AR    may    eventually    lead    to    other    complications.    These    include    chronic    sinusitis ,    recurrent inflammation   or   enlargement   of   the   adenoids   and   tonsils ,   chronic   ear   infections   (otitis   media)   and   ear   dysfunction.   Nasal   polyps   have   also   been associated with AR, though the connection is unclear.   Treatment- What to do ? The most important part of treatment is to understand the recurrent and prolonged nature of the disease process. While symptoms can be improved over the short-term with treatment, commitment to long-term treatment with follow-up to exclude complications and optimise drug dosage is vital. Stopping the treatment completely just when symptoms are receding would almost certainly bring them back again. That would bring the patient and the doctor back to square one ! The best way to treat AR is to avoid or limit exposure to the allergen as much as possible. Therefore, it is important to identify the allergens. Avoidance techniques will vary depending on the type of allergy. The principles in the management of AR include: Medication:   this   includes   the   use   of   nasal   steroid   sprays,   topical   decongestants,   antihistamine   tablets, leukotriene modifiers as prescribed by your ENT doctor. House dust mite (HDM) avoidance: o Change bed linen every week, pillow cases daily and wash bedding in hot water to kill mite o Remove carpeting, drapes, wall hangings and other dust accumulators o Wet mop and vacuum frequently o Replace stuff toys (eg. teddy bears) with metal, wooden and plastic ones o Dehumidifiers and HEPA air purifiers/filters Pets:   People   allergic   to   their   pets   should   remove   the   animals   from   the   house,   if   possible,   or   at   least keep   the   animals   out   of   the   bedroom.   Bathe   the   pets   frequently   to   minimize   the   amount   of   allergens   on their skin. Surgery:   eg.   trimming   of   the   inferior   turbinate   to   relieve   nasal   obstruction   resulting from   swollen   turbinates   for   the   long   term.   Chronic   rhinosinusitis   and   nasal   polyps   may need     Functional     Endoscopic     Sinus     Surgery (FESS) and polyp removal under general anesthesia. Immunotherapy:    Taken    when    allergies    cannot    be    controlled    by    avoidance    or medications.    Administered    over    a    period    of months   or   years,   these   drops   below   the   tongue   (sublingual   immunotherapy   SLIT)   can help   people   build   up   a   tolerance   to   their   allergen triggers.   This,   in   turn,   can   lead   to   the   prevention   or   reduction   of   allergy   symptoms. Immunotherapy   holds   the   promise   to   the   ‘cure’ of allergies. Understanding the myths of AR "Will it turn into a cancer?" NO ! Long term AR or sinusitis has not been linked with cancer. "Will   it   continue   forever?" The   severity   of AR   symptoms   usually   improves   as   a   patient   ages.   While   some   people   eventually   outgrow   the   disease   or the   disease   improves   over   the   years,   the   condition   can   worsen   over   time   in   some   people.   Therefore,   it   is   best   to   assume   that   you   have   it   for   the longer term and learn to manage it.  In short, one just cannot afford to be satisfied with the success of short-term management. "It   can't   be   cured. "    Immunotherapy   offers   hope.   However,   many   researches   are   still   ongoing.   There   are   still   debates   about   the   exact   dosage, schedule, and frequency. Also, in a person with multiple allergies, this option may not be feasible.
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
A common house duct mite - so tiny that it is invisible to the naked eye (source: IMR)
Allergic Rhinitis- 3-fold Pamphlet version (English language)
Allergic Rhinitis- 3-fold Pamphlet version (Chinese language)
Ways to reduce house dust mite exposure (English language)
(PDF files will open in a new window)
Ways to reduce house dust mite exposure (Bahasa Malaysia/Malay language)
Cara mengurangkan pendedahan pada hama debu
Flower and pollen  (picture courtesy of Dr. J See)
Runny nose - a common symptom © Vincent Tan ENT
Enlarged nasal  turbinate (arrows)
© Vincent Tan ENT
Enlarged tonsils (arrows) © Vincent Tan ENT Acute sinusitis - Nasal endoscopy showing pus in the right maxillary sinus  © Vincent Tan ENT
Soft toys - a cosy place for the dust mite to thrive
© Vincent Tan ENT
Pets -cute but can be a problem.. © Vincent Tan ENT
Copyright Vincent Specialist Solutions Sdn Bhd 2016. All rights reserved
•	Defined as a symptomatic disorder of the nose, induced after allergen exposure, by an IgE- mediated inflammation of the nasal membranes. (Ig-E is the antibody associated with allergy response) •	Incidence: 10 to 25% of population. •	Not a life-threatening disease but can significantly affect one’s social life, school performance and work productivity •	Symptoms: Rhinorrhea, Nasal obstruction, Nasal itching, Sneezing and the complications •	Reversible with avoidance or with treatment
...but..the trouble with allergic rhinitis is...
‘Sublingual Immunotherapy’ -drops underneath the tongue © Vincent Tan ENT
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D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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