One of Australia’s few dedicated rhinologists shares his insights

Allergic rhinitis, and conditions that mimic it, are common presentations in general practice that require accurate diagnosis and appropriate therapy to alleviate symptoms that often impact significantly on quality of life, says Professor Richard Harvey, one of only a few dedicated rhinologists in Australia.

The burden of allergic rhinitis in Australia is significant, “if you survey the Australian community only a fraction of patients will feel that it’s mild, the vast majority will feel it is moderate to severe,” says Professor Harvey.

“As a whole we are all guilty as a medical profession for believing it is a mild condition and we often trivialise these symptoms,” Professor Harvey says.

“It is very important to acknowledge that although patients present with allergic symptoms, it is actually a sign of an activated immune system which often affects people in a way we don’t appreciate. It makes them feel tired, run down, lethargic and often affects their concentration performance.”

The Ten Tips and Traps of Allergic Rhinitis

1. Don’t underestimate the impact of the condition
2. Don’t let the patient self-diagnose
3. Age is a useful predictor
4. Allergic changes are well described in the nose
5. Learn how to read your own sinus images
6. Can’t operate your way out of congestion
7. Tissue remodelling occurs in the allergic nose
8. Beware the nose that reacts in ways that aren’t allergic in origin, e.g. cold air
9. Beware the older patient (over 40) with strong post-nasal drip
10. Go strong on initial pharmacotherapy and then down titrate

Professor Harvey says there are ten ‘tips and traps’ when it comes to managing and diagnosing the condition, and it’s important to listen carefully to the symptoms patients report to differentiate rhinitis from other conditions such as bacterial sinusitis. “Those who have true bacterial infection of their nose almost universally get it unilaterally. So those patients who continue to complain of bilateral mucus and congestion, almost always after a cold, almost certainly don’t have a bacterial infection”.

Age is also a useful predictor when making a diagnosis, with younger patients being far more likely to have rhinitis than older patients. If you’re under the age of 30 and complain of sinonasal symptoms, the chance that you have a rhinitis going on is very high, with a diagnostic odds ratio above 8”. On the contrary, patients who are over 40 and are presenting with sinonasal symptoms are not only more likely to have sinus disease, but also more likely to have reflux with secretions giving the sensation of upper airway irritation, Professor Harvey says.

It is also important to learn to interpret CT scan reports carefully as CT is very good at detecting any mucosal thickening, and a lot of variations in normal.

“Almost every sinus CT report seems to indicate that patients have some form of sinusitis. But if you look at the scans themselves you will see there’s a lot of overreporting that comes into play’.

When it comes to management, going hard and going early with pharmacotherapy is key.

“It is important to go strong and then titrate back.” Combination therapies of antihistamine and intranasal corticosteroid are a good start as “we simply don’t’ have a single treatment that is 100% effective at treating symptoms” says Professor Harvey. “You should see a response in 7 – 14 days and if they don’t have a response you may need to refer on to see what can be done.”

If symptoms are effectively managed but remain perennial and persistent, referral for consideration of immunotherapy may be appropriate. Unlike standard pharmacotherapy that downregulates the immune response, immunotherapy can address the underlying atopic drive and modify it rather than supress it.

Select patients may require surgical intervention, but pharmacotherapy remains the mainstay of treatment as the underlying pathophysiology is allergic in nature.

“As a surgeon you cannot operate your way out of nasal congestion. If relieving nasal blockage and congestion meant simply cutting things out of the nose and creating space, we would have solved that problem a long time ago.”

To hear more from Professor Harvey on this topic, sign up for Healthed’s 30 May webcast here.