I. Definition
Allergic rhinitis is a chronic inflammatory disease of the nasal mucosa caused by IgE-mediated release of mediators (mainly histamine) in atopic individuals after exposure to allergens and the involvement of multiple immunoreactive cells and cytokines. There is a global trend of increasing prevalence of allergic rhinitis year by year.
Although allergic rhinitis is not a serious disease in itself, it can affect the quality of life (sleep, study, work, social and recreational activities) of patients and can lead to bronchial asthma, rhinosinusitis, nasal polyps, otitis media, etc., or occur simultaneously with allergic conjunctivitis. Allergic rhinitis is one of the risk factors for bronchial asthma, and the two diseases often occur simultaneously or sequentially. Due to the close connection between the two diseases in epidemiology, pathophysiology and immunology.
The close connection between the two diseases in terms of epidemiology, pathophysiology and immunology, and the commonality in many aspects of treatment principles suggest that the inflammatory response of the upper and lower airways is consistent. Active treatment of allergic rhinitis is one of the effective measures to prevent or reduce bronchial asthma. Therefore, the diagnosis and treatment of allergic rhinitis should pay attention to the assessment of the presence of bronchial asthma, and the corresponding treatment should be given in collaboration with respiratory physicians.
Classification and grading
The WHO working group on “allergic rhinitis impact on asthma” (AR IA) (2001) recommended a new classification based on the onset, duration and impact on the quality of life of the patient as follows:
Traditionally, patients are classified into seasonal allergic rhinitis and perennial allergic rhinitis according to the seasonality of the onset of the disease, and the seasonal and perennial classification can still be used in clinical work. In order to adapt to the actual situation in China, the traditional classification and the ARIA recommended classification method are combined to make the following classification for scientific research: seasonal intermittent, seasonal persistent; perennial intermittent and perennial persistent.
Seasonal rhinitis or pollinosis: the season of onset is basically the same every year, and it corresponds to the pollination period of the allergenic pollen (clinical studies should report at least 2 years in the same season), and the positive allergen skin test is mainly based on outdoor allergens (pollen); perennial rhinitis The positive allergen skin test was mainly for indoor allergens (mites, house dust, etc.). The degree of mild and moderate severity of the disease is based on the grading criteria specified by AR IA, changing the previous rule of grading the disease by the level of the score.
Diagnosis
1. Medical history: Take a detailed medical history, analyze the time of symptom onset and triggering factors, the presence of asthma, and assess the severity of symptoms. At least three of the four symptoms of nasal itching, sneezing, nasal discharge and nasal congestion should be present, and the symptoms should be accumulated for more than 0.5-1 h daily during the days of symptoms in perennial cases.
2. Examination: Nasal examination shows pale, edematous or congested, swollen nasal mucosa. Patients with hay fever often have obvious conjunctival congestion and edema, and in severe cases, eyelid swelling. Eosinophil smear of nasal secretions and/or conjunctival scrapings are positive during the onset of the disease. Positive allergen skin test, at least one of which is (++) or (++) or more. If available, serum or nasal secretion-specific IgE testing is indicated. If necessary, perform allergen nasal mucosal excitation test.
3. To facilitate the observation of the efficacy of the treatment, the following scoring criteria were established: symptom scoring method
See Table 1.
Table 1 Symptom scoring criteria
Grading score Sneezing ○ Runny nose △ Nasal congestion Nasal itching
1 point 3~5 ≤4 Conscious inhalation sensation Intermittent
2 points 6 to 10 5 to 9 Intermittent or reciprocal anasarca, but tolerable
3 points ≥11 ≥10 Breathing through the mouth almost the whole day, antsy feeling, unbearable
Note: Number of sneezes in a row; △Nose blowing times per day
Signs scoring criteria: the inferior turbinate is close to the nasal floor and nasal septum, the middle turbinate is not visible, or the middle turbinate mucosal polyp-like changes, polyp formation, recorded as 3 points; the inferior turbinate is close to the nasal septum (or nasal floor), there is still a small gap between the inferior turbinate and the nasal floor (or nasal septum), recorded as 2 points; the turbinate is mildly swollen, the septum and middle turbinate are still visible, recorded as 1 point.
IV. Treatment
1.Avoid contact with allergens: No matter what kind of treatment is used, we must try to minimize contact with allergens, although it is impossible to avoid them completely, but it is a necessary part of the treatment strategy.
2, drug therapy: In recent years, due to the introduction of efficient, long-lasting, safe drugs, drug therapy in the treatment of allergic rhinitis occupies an important position. Recommended medication regimen:
Mild allergic rhinitis: oral or intranasal local application of antihistamines and/or low-dose local application of glucocorticoids in the nasal cavity, if the symptoms do not improve satisfactorily, another antihistamine can be used or the number of local application of glucocorticoids in the nasal cavity can be increased. Short-term (less than 7 d) topical nasal decongestants can be applied according to the characteristics of the symptoms. In children, intranasal glucocorticosteroids with lower bioavailability are used, and the recommended dose of the drug is sprayed once a day; mast cell membrane stabilizers can be used in children with mild symptoms.
(2) Moderate to severe allergic rhinitis: topical nasal glucocorticoids or topical nasal glucocorticoids + short-term oral or intranasal topical antihistamines. If the nasal mucosa is highly edematous and/or combined with bronchial asthma, short-term (7-10 d) application of oral glucocorticoids may be considered followed by topical nasal glucocorticoids.
③ Combined allergic conjunctivitis: apply ophthalmic antihistamines or mast cell membrane stabilizers in eye drops.
④ Combined bronchial asthma: glucocorticoid bronchial inhalation, or oral leukotriene antagonist, etc. In case of severe asthma attack, respiratory medicine consultation should be requested. It is not recommended to apply nasal drops containing dexamethasone, nor is it recommended to use long-acting glucocorticoid preparations for intranasal or intramuscular injection.
For antihistamines with side effects of drowsiness, attention should be paid to the time of administration and the nature of the patient’s occupation. Antihistamines with cardiotoxic effects should be used with caution, prescribed in strict accordance with the recommended dose, and with attention to their contraindications. The use of decongestants should pay attention to the occurrence of drug rhinitis and cardiovascular effects. Young children and children: antihistamines with drowsy effects can affect the learning ability of children. The possible effects of certain glucocorticoids on the growth and development of the child should be considered. Pregnant women: Due to the lack of clinical trial results, attention should be paid to the selection of drugs and the use of mast cell membrane stabilizers or intranasal glucocorticoids with low bioavailability in accordance with recommended doses.
3, immunotherapy: standardized allergen vaccine or dip should be selected for specific immunotherapy, adherence to treatment for 3 to 5 years is usually effective. Immunotherapy, should strictly grasp the indications:
①Patients who are not satisfied with the effect of drug therapy;
②Patients with combined bronchial asthma;
③Patients with persistent cough (especially nocturnal cough);
④Patients with positive reactions to various allergens. Patients should be closely observed and monitored during immunotherapy, and the dosage should be reduced promptly in case of adverse reactions, and the treatment should be stopped in serious cases.
4.Some immunomodulators and surgical treatment (partial inferior turbinatectomy) can have certain effect.
5.Other therapies: randomized controlled clinical trials should be conducted to objectively assess their efficacy.
V. Efficacy evaluation criteria
According to the symptoms and signs to assess the efficacy of the score, scoring method: total score before treatment – total score after treatment
Total score before treatment × 100% ≥ 66% for effective, 65% ~ 26% for effective, ≤ 25% for ineffective.
A control group (including immunotherapy) should be set up for clinical studies and data summaries, and the scores of symptoms and signs of seasonal allergic rhinitis before and after treatment should be compared with the number and type of pollen dispersed in the air in the local area and year. The efficacy should be evaluated in the immediate and long term, the former at the end of the observation of the specific treatment, and the latter after 1 to several years.
Question.
1. Which aspects of the treatment system for allergic rhinitis are included?
A Drug therapy.
B Immunotherapy.
C Avoidance of allergens.
D Physician-patient education.
E Including the above four items.
2.What is the first-line medication for allergic rhinitis? A Antihistamines
B Nasal glucocorticoids.
C Systemic glucocorticosteroids.
D Mast cell stabilizers.
E Immunotherapeutic drugs.
3.What are the main symptoms of allergic rhinitis?
A Paroxysmal sneezing.
B Nasal itching.
C Nasal congestion.
D Clear watery mucus.
E Sometimes accompanied by dullness and pain in the head and loss of sense of smell.
4.What are the comorbidities of allergic rhinitis?
A Allergic conjunctivitis.
B Nasal polyp.
C Bronchial asthma.
D Sinusitis, otitis media, pharyngitis.
E Including all of the above.