ASEHA Qld

Aeroallergens and Upper respiratory tract conditions - Rhinitis, Conjunctivitis and Sinusitis.

By Dr Sharyn Martin PhD

In the last three articles common sources of airborne allergens and irritants as well as some of the adverse health effects resulting from exposure to these were described. In the next series of articles the health effects will be described in more detail. This article deals with the allergic and non-allergic upper respiratory tract conditions resulting from exposure to airborne allergens/irritants.

The Upper Respiratory Tract – the nose and eyes.

Rhinitis is characterised by one or more of the following symptoms – nasal congestion, runny nose, sneezing and itching.

Conjunctivitis is characterised by one or more of the following symptoms – redness of the eye, tearing, itching and burning of the eye.

Sinusitis is characterised by one or more of the following symptoms – nasal congestion, green or grey nasal discharge, post nasal drip, pressure in the face and headache

Rhinitis/conjunctivitis is common in the population, affecting 20-40% of the western population. It can be the result of allergic reactions or  non-allergic irritant mechanisms. Allergic rhinitis tends to occur in patients with a genetic predisposition to developing allergies. Regardless of what the mechanism is the symptoms are very similar (nasal congestion, sneezing, sore, itchy eyes). Allergic and non allergic rhinitis can co-exist resulting in a mixed rhinitis condition and this increases the number of substances that can induce symptoms.   Sinusitis can develop in people with chronic allergic or non- allergic rhinitis (rhinosinusitus). The resulting chronic inflammation of the sinus and mucus linings results in bacteria not be cleared from the sinus causing secondary bacterial infections.

Allergic rhinitis/conjunctivitis

Allergic rhinitis and conjunctivitis are common allergic inflammatory diseases caused by hypersensitivity to a range of allergens that cause inflammation of the mucosa of nose (rhinitis) and eyes (conjunctivitis).

The symptoms involve  the anterior aspects of the nose and can also affect the eyes, throat, sinuses, ears and include runny nose, watery eyes, itching nose throat or eyes, tearing of eyes, blocked nose, sneezing, itchy skin, headaches, sore throat. Other symptoms may include difficulty to concentrate, listlessness and irritability.  Asthma may develop, especially if the individual is particularly sensitive and exposed to high levels of allergen.

Allergic Triggers - Aeroallergens such as the  Seasonal allergens e.g. pollen, or Perennial allergens e.g. house dust mites, cockroaches.

The symptoms may occur  Seasonally(at particular times of the year), known as Hayfever  or Perennially (All year) .

The Table below shows the differences between them.

Perennial allergic rhinitis and conjunctivitis.	Seasonal allergic rhinitis and conjunctivitis (Hayfever)
Where and when Allergens found:  mainly Indoor and all year round	Where and when Allergens found: both Outdoor and Indoor, during Spring and Autumn
Allergens/Triggers: House dust mites, cockroaches, animal dander and moulds	Allergens/Triggers: Pollen of weeds, trees and grasses, seasonal moulds
Symptoms: Nasal - Nasal blockage more pronounced than in seasonal rhinitis, runny nose, sneezing and itching, Eyes - Redness, tearing, itching and burning of the eyes	Symptoms: Nasal - Bouts of sneezing, nasal itch, Eyes - Tearing of eyes, burning, stinging, sensitive to light, redness and watery eyes

 

Non Allergic Rhinitis

Non allergic rhinitis is also an inflammatory condition involving the nasal mucosa, except that in these cases the inflammation is not a result of an allergic, IgE mediated inflammatory mediator release. The underlying mechanisms leading to various forms of non-allergic rhinitis are variable and less well understood than allergic rhinitis. Non allergic rhinitis is also referred to as idiopathic rhinitis.

Non-allergic rhinitis triggers tend to cause changes to the mucosal membranes that lead to damage of the nasal mucosa or cause inflammation. It can become a chronic condition complicated by allergic rhinitis and there is a potential to the develop chronic sinusitis as a result.

The symptoms of non-allergic rhinitis are nasal congestion and runny nose. Where it differs from allergic rhinitis is that there is rarely significant itching or sneezing, though if the condition is a Mixed allergic and non allergic rhinitis, all symptoms can co exist.

Triggers - Nasal symptoms are triggered by a wide range of non-allergens including environmental irritants such as Car & diesel exhaust, Perfume and fragrance, Volatile Organic Compounds (VOC’s),  Cleaning products, Incense, Newsprint, Hairspray, strong smells and irritants, changes in weather and barometric pressure, hormonal fluctuations, and ingestion of alcohol or certain foods.

 

Comparison of Allergic and Non-Allergic Rhinitis

The information below describes the differences between allergic and non allergic rhinitis.

Onset of condition

Allergic rhinitis usually presents in childhood and there is typically a strong family history of atopic diseases including rhinitis, asthma, and atopic dermatitis.

Non-allergic rhinitis usually presents after the age of 20 (adult-onset nasal symptoms) and often there is no evidence of a familiar pattern. There is a strong female predominance in non-allergic rhinitis not seen in allergic rhinitis.

Allergens/Triggers of allergic and non-allergic rhinitis

Triggers of allergic rhinitis are aeroallergens, most commonly seasonal allergic rhinitis to pollens although perennial allergic rhinitis to allergens such as cat or dust mite does occur.  Symptoms are produced following exposure to cats, dogs, feathers, other furred animals and seasonal variations such as pollens.

People with non-allergic rhinitis generally have perennial symptoms. The triggers of Non-allergic rhinitis are broad and includes VOC’s, fragrance, particulate materials, as well as changes in weather and barometric pressure

Differences in symptoms

Allergic rhinitis has very significant sneezing and nasal itch and also has ocular symptoms with tearing and itch.

Non-allergic rhinitis usually involves only the nose, and typically have more nasal congestion and runny nose, and rarely have significant itching or sneezing

Diagnostic Tests

In allergic rhinitis laboratory tests include measurement of allergen specific IgE levels and allergen specific skin prick tests.  Raised levels of allergen specific IgE or a positive reaction to allergen on skin prick tests confirm a diagnosis of allergic rhinitis

In non allergic rhinitis there are no specific laboratory tests, allergens tests above are usually negative and is usually diagnosed by exclusion

Treatment

Treatment of allergic rhinitis can involve medications, allergen avoidance and immunotherapy.

Treatment of non-allergic rhinitis is almost solely with medications

Sinusitis –  Complication of Chronic Rhinitis (regardless of mechanism)

Poorly controlled rhinitis (either allergic or non allergic) can  lead to sinusitis. Sinusitis is an inflammation of the nasal sinuses and tends to cause symptoms involving the sinus cavities in the posterior aspects of the nose. Sinusitis may become a  long-term, chronic condition, complicated by allergies or structural problems in the nose. Chronic inflammation of the sinus and mucus linings prevents the usual clearance of bacteria from the sinus cavity, increasing the chances of developing secondary bacterial sinusitis. As the sinus cavities become inflamed, chemical mediators similar to those seen in allergic rhinitis are released leading to rhinitis symptoms.

Triggers

Sinusitis can occur following an acute inflammation caused by bacterial infection such as the common cold,  allergies or increased sensitivity to irritants such as smoke, perfume or VOC’s.

Symptoms

Thick mucus from the nose or down the back of the throat,  loss of sense of smell or taste,  bad breath / bad taste in the mouth,  sore throat, cough,  tiredness, temperature or shivers (fever),  facial congestion (a feeling of fullness) and pain,  headache, toothache, sensation of pressure in the face that is worse with leaning forward.

 

Summary information

To summarise the following table compares the symptoms suffered from a cold or flu attack with the different conditions resulting from exposure to allergens or irritants in the indoor and outdoor environment .

Viral Rhinitis (Cold/Flu)	Allergic Rhinitis/conjunctivitis	Non-Allergic Rhinitis	Sinusitis
Runny nose with watery to thick yellow nasal discharge Low grade fever Sneezing Weakness and fatigue	Congestion Runny nose with thin watery discharge Sneezing Wheezing Itchy nose, throat and eyes Tearing of eyes	Congestion Runny nose Post nasal drip Symptoms generally only involve the nose Headache	Congestion Green or grey nasal discharge Post nasal drip Pressure in the face Headache Cough
Symptoms appear one to three days post exposure to cold virus	Symptoms persist as long as exposed to allergen	Symptoms persist as long as exposed to irritants	Symptoms appear after a cold or triggered by allergies or irritants

In the next article I will explain the condition Vocal Cord Dysfunction, a disorder that affects respiratory function by causing the vocal cords to close on inhalation. The symptoms are similar to asthma and the condition is often confused with asthma, but unlike asthma it is not the lungs but the larynx (Throat) that is affected.

If you suspect you have an allergy, visit your GP or Allergy specialist.

 

Further Reading

ASEHA leaflets on Indoor and Outdoor Air pollution; Chemical Sensitivity; Pesticides; Skin Allergy

For more information on the allergic diseases and the prevention of allergic reactions to aeroallergens please visit the following sites.

ASCIA website http://www.allergy.org.au/content/category/3/48/241/ Provides information about the Allergenic Pollen plants, and what times of the year the plants usually flower all over Australia.

ASCIA www.allergy.org.au or www.ascia.org.au

Asthma Foundation www.asthmaaustralia.org.au

National Institute of Allergy and Infectious diseases http://www.niaid.nih.gov/

World Allergy Association www.worldallergy.org

RPAH allergy clinic  www.sswahs.nsw.gov.au/rpa/allergy/

National Asthma Council of Australia http://www.nationalasthma.org.au/content/view/460/632/#ar

Safe Cleaning Tips for Your Home http://www.ewg.org/schoolcleaningsupplies/safecleaningtips

References

ACAAI: Home is Where the Allergies Are. By Neil Osterweil,  Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine. November 14, 2006

Asthma A guide for health professionals and Air Pollution Australian Government  Department of Health and Ageing 2004 Australian Government Department of Health and Ageing 2004 in collaboration with the Australasian Society of Clinical Immunology and Allergy.

Bousquet J, W.Fokkens, P.Burney, S.R.Durham, C.Bachert, ,C.A.Akdis, G.W.Canonica, S.-E.Dahlen, T.Zuberbier, T.Bieber’ S.Bonini,  P.J.Bousquet, J.L.Brozek, L.-O.Cardell, R.Crameri, A.Custovic, P.Demoly, ,R.G.vanWijk, M.Gjomarkaj, C.Holland, P.Howarth, M.Humbert, S.L.Johnston, F.Kauffmann, M.L.Kowalski, B.Lambrecht, S.Lehmann, B.Leynaert, K.Lodrup-Carlsen, J.Mullol, B.Niggemann, E.Nizankowska-Mogilnicka, N.Papadopoulos, G.Passalacqua, H.J.Schnemann, H.-U.Simon, A.Todo-Bom, E.Toskala, R.Valenta, M.Wickman, J.P.Zock 2008. Review article. Important research questions in allergy and related diseases: non allergic rhinitis: a GA2 LEN paper Allergy 2008: 63: 842–853

Brandt D, Bernstein JA 2006. Questionnaire Evaluation and Risk Factor Identification for Nonallergic Vasomotor Rhinitis Ann Allergy Asthma Immunol. 2006;96:526-532

Corsinia E, and Kimberb I. 2007 Letters. Volume 168, Issue 3, Pages 255-259

Elberling J,  Linnebergw A, Dirksenz A, Johansen J. D. , Frlund§ L.F., Madsen§, N. H. Nielsenz  and H. Mosbech 2005. Mucosal symptoms elicited by fragrance products in a population-based sample in relation to atopy and bronchial hyper-reactivity Clin Exp Allergy 2005; 35:75–81

Environmental Health Perspectives Volume 107, Number 7, July 1999, Focus A Healthy home Environment

Mølgaard E, Thomsen SF, Lund T, Pedersen L, Nolte H,  Backer V. 2007. Differences between allergic and nonallergic rhinitis in a large sample of adolescents and adults Allergy: 62: 1033–1037.

Rios and  Mullol World Allergy Organization XXI World Allergy Congress (WAC): Abstract 707. Presented December 8, 2009

Rondón C; Canto G; Blanca M 2010. Local Allergic Rhinitis: A New Entity, Characterization and Further Studies, Curr Opin Allergy Clin Immunol. 2010;10(1):1-7

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Institute of Allergy and Infectious Diseases NIH Publication No. 03-7045 April 2003  www.niaid.nih.gov

 

 

 

 

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