It is an IgE-mediated immunologic response of nasal mucosa to airborne allergens and is

characterized by watery nasal discharge, nasal obstruction, sneezing and itching in the nose. This
may also be associated with symptoms of itching in the eyes, palate and pharynx. Two clinical types
have been recognized:

1. Seasonal. Symptoms appear in or around a particular season when the pollens of a particular
plant, to which the patient is sensitive, are present in the air.

2. Perennial. Symptoms are present throughout the year.

Etiologi

Inhalant Allergens. They may be seasonal or perennial. Seasonal allergens include pollens from trees,
grasses and weeds. They vary geographically. The knowledge of pollen appearing in a particular area
and the season in which they occur is important. Their knowledge also helps in skin tests. Perennial
allergens are present throughout the year regardless of the season. They include molds, dust mites,
cockroaches and dander from animals. Dust includes dust mite, insect parts, fibres and animal
danders. Dust mites live on skin scales and other debris and are found in the beddings, mattresses,
pillows, carpets and upholstery.

Genetic Predisposition. plays an important part. Chances of children developing allergy are 20 and
47%, respectively, if one or both parents suffer from allergic diathesis.

Patogenesis

Inhaled allergens produce specific IgE antibody in the genetically predisposed individuals. This
antibody becomes fixed to the blood basophils or tissue mast cells by its Fc end (Figure 30.1 ). On
subsequent exposure, antigen combines with IgE antibody at its Fab end. This reaction produces
degranulation of the mast cells with release of several chemical mediators, some of which already
exist in the preformed state while others are synthesized afresh. These mediators (Figure 30.2) are
responsible for symptomatology of allergic disease. Depending on the tissues involved, there may be
vasodilation, mucosal oedema, infiltration with eosinophils, excessive secretion from nasal glands or
smooth muscle contraction. A “priming affect” has also been described, i.e. mucosa earlier sensitized
to an allergen will react to smaller doses of subsequent specific allergen. It also gets “primed” to
other nonspecific antigens to which patient was not exposed Nonspecific nasal hyper-reactivity is
seen in patients of allergic rhinitis. There is increased nasal response to normal stimuli resulting in
sneezing, rhinorrhoea and nasal congestion. Clinically, allergic response occurs in two

phases:

1. Acute or early phase. It occurs immediately within 5–30 min, after exposure to the specific
allergen and consists of sneezing, rhinorrhoea nasal blockage and/ or bronchospasm. It is due to
release of vasoactive amines like histamine.

2. Late or delayed phase. It occurs 2–8 h after exposure to allergen without additional exposure. It is
due to infiltration of inflammatory cells—eosinophils, neutrophils, basophil, monocytes and CD4 + T
cells at the site of antigen deposition causing swelling, congestion and thick secretion. In the event of
repeated or continuous exposure to allergen, acute phase symptomatology overlaps the late phase.
Clinical features

There is no age or sex predilection. It may start in infants as young as 6 months or older people.
Usually the onset is at 12–16 years of age.

The cardinal symptoms of seasonal nasal allergy include paroxysmal sneezing, 10–20 sneezes at a
time, nasal obstruction, watery nasal discharge and itching in the nose. Itching may also involve
eyes, palate or pharynx. Some may get bronchospasm. The duration and severity of symptoms may
vary with the season.

Symptoms of perennial allergy are not so severe as that of the seasonal type. They include frequent
colds, persistently stuffy nose, loss of sense of smell due to mucosal oedema, postnasal drip, chronic
cough and hearing impairment due to eustachian tube blockage or fluid in the middle ear.

Signs of allergy may be seen in the nose, eyes, ears, pharynx or larynx.

• Nasal signs include transverse nasal crease—a black line across the middle of dorsum of nose due
to constant upward rubbing of nose simulating a salute (allergic salute), pale and oedematous nasal
mucosa which may appear bluish. Turbinates are swollen. Thin, watery or mucoid discharge is
usually present.

• Ocular signs include oedema of lids, congestion and cobble-stone appearance of the conjunctiva,
and dark circles under the eyes (allergic shiners).

• Otologic signs include retracted tympanic membrane or serous otitis media as a result of
eustachian tube blockage.

• Pharyngeal signs include granular pharyngitis due to hyperplasia of submucosal lymphoid tissue. A
child with perennial allergic rhinitis may show all the features of prolonged mouth breathing as seen
in adenoid hyperplasia.

•Laryngeal signs include hoarseness and oedema of the vocal cords. subdivided into intermittent or
persistent and severity of disease into mild, moderate or severe.This new system of classification
helps in treatment guidelines. A detailed history and physical examination is helpful, and also gives
clues to the possible allergen. Other causes of nasal stuffiness should be excluded.