ALLERGIC RHINITIS AND ITS MANAGEMENT
Allergic rhinitis, which many of us know as “Hay Fever”, is a common condition that affects many people around the world, including in Singapore.
HOW COMMON IS ALLERGIC RHINITIS?
Hay fever affects about 10-30% of people worldwide. In Singapore, because of its warm and urban environment, about 20-30% of people have hay fever.
WHAT CAUSES ALLERGIC RHINITIS?
When someone who is sensitive to certain substances (allergens) breathes them in, their body tries to fight off these allergens. This reaction causes the nose to become inflamed.
WHAT ARE THE MAIN ALLERGENS WORLDWIDE AND IN SINGAPORE?
- Globally, tree, grass, and weed pollen are frequent hay fever triggers.
- In Singapore, house dust mites are the primary concern.
Additional irritants in Singapore and globally include:
- Pet hair
- Mould
- Cockroach droppings
WHAT ARE THE COMMON SYMPTOMS OF NASAL ALLERGIES?
Allergic rhinitis, manifests with a variety of symptoms that result from the body’s reaction to air borne allergens. The common symptoms include:
- Sneezing: Often in bouts or sequences, often in the morning.
- Runny nose: Clear, watery nasal discharge.
- Nasal congestion: A stuffy or blocked nose.
- Itchy nose: An urge to scratch the inside of the nose.
- Itchy eyes: Along with redness and watering of the eyes.
- Itchy throat: Sometimes leading to a cough or throat clearing.
- Swollen, blue-coloured skin under the eyes: Often referred to as “allergic shiners”.
- Postnasal drip: Sensation of mucus dripping from the back of the nose into the throat, which can lead to cough or a sore throat.
- Reduced sense of smell: Due to nasal congestion.
- Fatigue: Due to disrupted sleep or the body’s reaction to allergens.
- Worsening of asthma: In some people, allergic rhinitis can also trigger or exacerbate other symptoms or conditions, such as asthma or eczema.
If one experiences these symptoms regularly or in particular seasons, it may be indicative of allergic rhinitis. It’s advisable to see a healthcare professional, like an ENT specialist, for an accurate diagnosis and appropriate management.
WHY DO SOME PEOPLE GET HAY FEVER?
There are two main reasons:
- Genetic predisposition: If family members have allergies, one is more likely to develop hay fever.
- Exposure to allergens: High exposure to triggers at an early age can increase the risk.
- Being born during pollen season: There is some evidence to suggest that those born during high pollen seasons may be more susceptible.
- Having other allergies or asthma: Those with existing allergies or asthma are more likely to develop hay fever.
- Living or working in an environment that constantly exposes one to allergens can also heighten the risk.
HOW IS ALLERGIC RHINITIS DIAGNOSED?
HISTORY AND EXAMINATION
Dr Sandeep gathers a detailed history of symptoms and their occurrences. A comprehensive ENT examination is performed, and a nasal endoscopy is conducted to check for:
- Enlarged, pale and boggy nasal turbinates.
- Deviated septum.
- Presence of polyps or other pathology.
- Signs of sinus infection like mucous or pus emanating from the nasal sinuses.
TESTS FOR ALLERGY
These tests help determine the specific allergens causing the symptoms.
- Skin Prick Test (SPT): Small amounts of allergens are introduced into the skin. If there’s a reaction, it suggests an allergy to that specific allergen.
- Blood Test (RAST or ImmunoCAP): Allergy panel measures the amount of allergen specific IgE antibodies in the blood.
HOW IS ALLERGIC RHINITIS TREATED?
The approach to treating allergic rhinitis is multiprong, the aim is symptom control.
ALLERGEN AVOIDANCE
The first step is to identify and avoid triggers.
House Dust Mite Avoidance
- Encase Mattresses and Pillows: Use allergen-proof covers to keep mites out.
- Wash Bedding Regularly: Wash sheets, blankets, and pillowcases weekly in hot water (at least 60°C) and dry them in a hot dryer.
- Reduce Humidity: Keep home humidity below 50% using dehumidifiers or air conditioners.
- Remove Carpeting: Where possible, replace carpets with hardwood, tile, or linoleum flooring.
- Regular Cleaning: Vacuum weekly using a vacuum cleaner with a HEPA (high-efficiency particulate air) filter. Wear a mask while vacuuming.
- Declutter: Dust mites thrive in clutter. Reduce items that collect dust, like knick-knacks and books.
- Clean Curtains and Upholstery: Wash with hot water or vacuum regularly with a vacuum cleaner with a HEPA (high-efficiency particulate air) filter items like bed linen and curtains, and consider using blinds instead of fabric curtains.
- Air Purifiers: Use air purifiers with HEPA filters to reduce airborne allergens.
Soft Toys and Allergen Avoidance Measures
Soft toys can be a haven for dust mites and allergens, especially if they are frequently handled or placed in areas prone to dust accumulation. If someone in the household has allergies, particularly to dust mites, it’s essential to take measures to keep soft toys as allergen-free as possible. Here are some measures to reduce allergens in soft toys:
- Regular Cleaning: Wash soft toys in hot water (at least 60°C) regularly. Ensure they are thoroughly dried before giving them back to children.
- For toys that can’t be washed, placing them in a plastic bag and freezing them overnight can kill dust mites. After removing them from the freezer, let them return to room temperature, and then give them a good shake or vacuum to remove dead mites.
- Storage: Store soft toys in closed cabinets or toy boxes to prevent dust accumulation.
- Avoid placing soft toys on beds, especially if they aren’t regularly cleaned, as this can be a significant source of allergens.
- Limit Number of Soft Toys: Consider having fewer soft toys, especially in sleeping areas. This reduces potential allergen accumulation points.
- Choose Allergen-Friendly Toys: Opt for toys labelled as hypoallergenic. These toys are made of materials less likely to provoke an allergic response.
- Avoid Second-hand Soft Toys: If possible, refrain from using second-hand soft toys, as their previous environment might have exposed them to a variety of allergens.
- Use Protective Covers: Use allergen-proof covers or bags for toys, especially those that children might take to bed with them.
- Regular Air Out: Periodically let soft toys air outside in direct sunlight. The ultraviolet light from the sun can help reduce the number of dust mites.
- Vacuuming: If the toy can’t be washed or frozen, vacuum it regularly using a vacuum cleaner with a HEPA filter. This can help remove surface dust and allergens.
By implementing these measures, one can reduce allergen exposure from soft toys and create a healthier environment, especially for children who are more susceptible to allergens.
Pollen Allergen Avoidance
To avoid pollen and reduce hay fever symptoms, consider the following strategies:
- Monitor pollen forecasts and stay indoors when counts are high.
- Keep windows closed during high pollen seasons to prevent spores from entering your home or car.
- Use air purifiers with HEPA filters to capture pollen indoors.
- Shower and change clothes after being outdoors to remove pollen from your body and attire.
- Consider wearing a pollen mask when doing outdoor activities, especially gardening or lawn mowing.
- Start using allergy medications before the pollen season begins.
- Wash bedding regularly in hot water to eliminate any pollen that may be brought indoors.
- Avoid drying clothes outside during pollen season to prevent pollen from sticking to fabrics.
Minimize Exposure To Pet Dander
To minimize exposure to pet dander and manage allergies, here are some useful tips:
- Bathe pets regularly to reduce the amount of dander they shed.
- Keep pets out of bedrooms and off upholstered furniture to limit dander in living spaces.
- Vacuum frequently using a vacuum with a HEPA filter to trap pet dander.
- Use air purifiers in areas where pets spend the most time to filter out dander from the air.
- Wash your hands after handling pets, especially before touching your face or eyes.
- Clean and dust your home regularly, as pet dander can settle on surfaces.
- Consider choosing pet breeds that are known to produce less dander.
- Use anti-allergen sprays on furniture and carpets to neutralize dander.
- Maintain a healthy diet for your pet to minimize shedding and dander production.
Mould Avoidance
To reduce exposure to mould and alleviate related allergies, follow these steps:
- Keep humidity levels in your home low, ideally between 30% and 50%.
- Use dehumidifiers in damp areas of your home to control moisture.
- Ensure adequate ventilation by using exhaust fans in bathrooms and kitchens.
- Fix leaky roofs, windows, and pipes promptly to prevent mould growth.
- Clean and dry any areas of water accumulation or flooding within 24-48 hours to prevent mould formation.
- Remove or replace carpets and upholstery that have been soaked and cannot be dried promptly.
- Use mould-resistant products like paints and building materials in areas prone to moisture.
- Regularly clean bathrooms with mould-killing products.
- Avoid using carpeting in areas like bathrooms or basements where moisture levels are high.
- Keep indoor plants to a minimum as the soil can be a breeding ground for mould.
By implementing these measures, one can significantly reduce exposure to allergens and improve symptoms associated with allergies. Regular cleaning and maintenance of the living environment play a crucial role in allergen avoidance.
MEDICATIONS
- Nasal Saline Irrigation: Rinsing the nasal passages with a saltwater solution can help remove allergens and clear nasal passages.
- Antihistamines: Reduce sneezing, runny nose, and itching. Examples include cetirizine, loratadine, and fexofenadine.
- Nasal Corticosteroids: Sprays like fluticasone, budesonide, and mometasone help reduce nasal inflammation.
- Decongestants: Provide temporary relief from nasal stuffiness. Examples are pseudoephedrine and phenylephrine.
- Leukotriene Modifiers: Such as montelukast, block the action of certain immune system chemicals.
- Nasal Cromolyn: Prevents the release of immune system chemicals that cause allergy symptoms.
- Allergen Immunotherapy: Allergy shots or sublingual tablets that gradually expose the patient to increasing amounts of the allergen, aiming to increase tolerance. Immunotherapy, also known as allergy shots or allergy vaccines, is a preventive treatment for allergic reactions to substances like grass pollens, house dust mites, and bee venom. Here’s a brief overview of how immunotherapy works and its application in Singapore:
- Principle: The basic idea behind immunotherapy is to gradually introduce the allergen to the patient’s system, so the body gets used to it and eventually stops reacting to it in the way that triggers symptoms.
- Procedure: It involves giving increasing amounts of the allergen to the patient over several months. This can be done through subcutaneous injections (allergy shots) or sublingual tablets or drops.
- Duration: Once the maintenance dose is reached, there will be longer intervals between treatments, ranging from 2-4 weeks. The total duration of the therapy can last between 3-5 years.
- Effectiveness: Over time, immunotherapy can reduce the symptoms and medication needs for people with allergic rhinitis and asthma. It can also help prevent the development of asthma in people with allergic rhinitis.
- Availability in Singapore: In Singapore, sublingual immunotherapy (SLIT) has become more popular, where patients take the allergen in the form of a tablet or drop under the tongue. It is considered more convenient by many, and its safety profile allows it to be taken at home after initial doses under medical supervision in Dr Sandeep’s practice.
Patients considering immunotherapy should consult with Dr Sandeep Uppal to understand the benefits, potential risks, and the commitment required for the treatment. Dr Sandeep is Fellowship trained in Advanced Rhinology and management of nasal allergies, under his guidance many patients find significant relief from their allergy symptoms through this approach.
SURGERY
Surgery is considered in patients who continue to have nasal blockage and discharge despite medical treatment.
Septoplasty/Septorhinoplasty
In cases with structural abnormalities like a deviated nasal septum or nasal valve collapse, surgery might be considered to improve the airway.
Turbinoplasty
Often the nasal turbinates are markedly enlarged leading to nasal blockage. The turbinates may be reduced to improve the nasal air flow.
Posterior Nasal Nerve Ablation
The posterior nasal nerve (PNN) is responsible for reflex symptoms like sneezing and nasal secretion. Ablation of this nerve is a surgical procedure used to reduce symptoms in patients with severe allergic rhinitis (AR) when other treatments have failed or are not as effective.
The goal is to reduce or eliminate the transmission of signals that cause sneezing and excessive nasal secretion in allergic rhinitis.
The procedure can be performed using various techniques such as radiofrequency ablation, cryoablation, or surgical ablation. The procedure typically takes about 15-30 minutes and can be done under local anaesthesia. Here is a summary of evidence to support this treatment:
Author & Year | Study Design | Number of Patients | Treatment Method | Outcomes |
Del Signore et al. (2022) | Controlled trial, multiple centres | 133 participants (Treatment: 68, Control: 65) | Cryotherapy ablation, Followed for 3 months | 73.4% of treated patients improved vs. 36.5% of control |
Hwang et al. (2017) | Prospective, multiple centres | 27 (AR: 13, NAR: 13, 1 excluded) | Cryotherapy ablation, Followed for 12 months | Significant symptom relief in both AR and NAR groups |
Ow et al. (2021) | Prospective, multiple centres | 27 (AR: 30, NAR: 70) | Cryotherapy ablation, Followed for 24 months | Significant symptom reduction at 12 and 24 months |
Chang et al. (2020) | Prospective, multiple centres | 98 participants | Cryotherapy ablation, Followed for 9 months | Significant symptom relief, more prominent in NAR |
Ehmer et al. (2022) | Prospective, multiple centres | 50 participants (AR: 21, NAR: 17, 12 unknown) | Radiofrequency neurolysis, Followed for 12 months | Significant symptom relief in both AR and NAR groups |
Note: AR refers to Allergic Rhinitis and NAR refers to Non-Allergic Rhinitis.
BREATHE EASY WITH EXPERT ALLERGIC RHINITIS CARE
If you’re struggling with hay fever or allergic rhinitis, don’t let your symptoms control your life. With Dr Sandeep Uppal and the dedicated team, you have a group of leading experts committed to providing exceptional care. Together, we will work to understand the root of your condition and craft a personalized treatment plan that fits your unique situation. Our goal is to manage your hay fever effectively so that you can enjoy life with minimal disruption.
Take the first step towards better managing your allergic rhinitis—book an appointment for a comprehensive evaluation. Stay proactive with regular follow-ups and be assured that we’re here to adjust your treatment plan for the best possible outcomes. Let us help you breathe easier; contact Dr Sandeep Uppal and his team today!