Chronic rhinitis in South Africa: Update 2013
R J Green,
FCS (SA) (ORL);
FC Paed (SA);
Dip Allergol (SA);
FCS (SA) (ORL);
(SA), Dip Allergol (SA), Cert Pulm (Paed) (SA);
1 Department of Paediatrics and Child Health, University of Pretoria, South Africa
2 Department of ENT Surgery, Netcare Linksfield Clinic, Johannesburg, South Africa
3 Mediclinic Sandton, Johannesburg, South Africa
4 Department of Paediatrics, Netcare Linksfield Clinic, Johannesburg, South Africa
5 Department of Otorhinolaryngology, University of the Free State, South Africa
6 Department of Paediatric Pulmonology and Allergy, Linksfield Clinic, Johannesburg, South Africa
7 Department of Paediatrics and Adolescent Health, University of Cape Town, South Africa
8 Department of Medicine, University of Cape Town, South Africa
Division of Pulmonology, Department
of Internal Medicine, University of the Witwatersrand,
Johannesburg, South Africa
On behalf of the South African Allergic Rhinitis Working Group. S Bouwer, G P Tunguy-Desmarais, A McCulloch, H Lewis, I Hunt, E Vardas, L Wolff, F Mokgoadi, M Gill, P Jeena, F Jooma, G J Joyce, T Moodley.
Endorsed by the
Allergy Society of South Africa.
The term rhinitis implies inflammation of the lining of
the nose. Characteristic symptoms are a blocked nose, anterior
and posterior rhinorrhea, sneezing and itching. Not all cases
of chronic rhinitis have an allergic basis. Chronic
non-allergic rhinitis is defined as a condition where ongoing
rhinitic symptoms are present for many months (as for
persistent allergic rhinitis)
but there is no IgE
basis. Many common conditions may present as chronic rhinitis,
which will need to be investigated and managed on their own
merits. Not all cases of chronic rhinitis respond to allergic
rhinitis therapy: continued attempts to manage chronic
rhinitis as allergic rhinitis may be hampered by
pathophysiological conditions where other specific therapy may
be required. Chronic rhinitis impacts on patient quality of
life, and therefore therapy is important. Managing patients
with chronic rhinitis requires attention to patient education
in order to achieve the maximal therapeutic benefit of
medication. This update is intended to provide clinicians with
a sound basis for management of a common condition.
S Afr Med J 2013;103(6):419-422.
The South African Allergic
Rhinitis Working Group (SAARWG) met on 6 April 2013 to discuss
and review important concepts in allergic rhinitis diagnosis
and management. The theme of that meeting, and this update, is
to remind clinicians that all patients with rhinitis may not
have allergic rhinitis (AR) specifically. The reason is
twofold: (i) patients with chronic rhinitis
(CR) may have one of a number of conditions that are more
significant and may herald more sinister diagnoses, and (ii)
many forms of chronic rhinitis may not respond as well to
standard allergic rhinitis therapy. This review will focus
specifically on the differential diagnosis of AR and the
management of these alternative conditions.
The term ‘rhinitis’ implies inflammation of the lining of
the nose. The characteristic symptoms are a blocked nose,
anterior and posterior rhinorrhea, sneezing and itching.1 Most
patients with AR have an IgE or type I allergic basis,2 and
the Allergic Rhinitis and its Impact on Asthma (ARIA) Working
Group has classified allergic rhinitis into 4 groups based on
symptom duration and symptom severity (Fig. 1).3
This classification has become important for South Africa,
because where grass pollen is a major allergen (such as across
the Highveld) the disease is usually persistent over several
months and usually moderate to severe in nature.4 In
contrast, chronic non-allergic rhinitis, by definition, is a
condition where ongoing rhinitic symptoms are present for many
months (as for persistent AR)3 but where there is no
IgE basis. A long list of conditions may present as CR (Table
Fig. 1. Classification of allergic
3. Prevalence of CR
South Africa was fortunate enough to be represented in the International Study of Asthma and Allergies in Childhood (ISAAC). Two centres (Cape Town and Polokwane) participated in this study of the epidemiology of allergic rhinitis. In Phase I of the ISAAC Study, conducted in 1995, questioning of 13 - 14-year-old subjects reported that the prevalence of AR was 30.4% in Cape Town.5 By Phase II of the study in 2003, the prevalence had gone up to 38.5%.6 In addition, that study revealed that AR’s impact on quality of life was becoming more significant.6 However, the major problem with these data is that although the subjects’ condition was labelled as AR, no testing for allergy was performed. This raises a concern about the above epidemiological definition of AR and its prevalence.
It is clear that when subjects are questioned on the presence of nasal symptoms, a significantly higher rate of symptoms is reported than for true AR. For example, in one study, although 48% of subjects reported chronic nasal symptoms, only 14.9% had true AR with a positive skin -prick test (SPT).7 This study emphasises that the term AR should not be used unless there is either a positive allergy test (either SPT or ImmunoCAP) or a clear history of symptoms triggered by specific allergens, possibly with a seasonal variation. If such evidence of allergy is not present, then the condition should be labelled as CR and the conditions listed in Table 1 should always be considered.
Another important consideration in defining AR is that a positive allergy test does not always confirm AR in isolation. Specific IgE may be a pointer to AR but specific symptoms need to be present before the diagnosis is made.8 Laboratory tests to confirm the diagnosis of AR should be selected based on careful history-taking, rather than applying a large panel of allergy tests.
In children the allergic component of CR may be more frequent
than in adults.
4. Climate change, urban air pollution and CR
We live in a dynamic environment, with rising average
temperature and increasing anthropogenic greenhouse gases, which
may increase the generation of pollen-producing plant species.9
Increased levels of pollutants such as carbon dioxide, ozone and
nitrogen dioxide enhance the allergic response,11 and
pollutants may induce their own form of irritant rhinitis.
Changes in vegetation biomes, as a result of climate change, are
likely to cause changes in outdoor pollen and fungal allergens.
Changes in the climate are expected to alter the presentation,
seasonality and epidemiology of allergic rhinitis and other
allergic respiratory diseases in future.
5. Impact of rhinitis on South Africans
In light of the statement above that most epidemiological studies of AR are in fact studies of CR, there are valuable lessons to be learned from studies of the impact of rhinitis on quality of life.12 Many South African studies have suggested that CR impacts significantly on patient quality of life and the major effect is impaired sleep.13-15] Trivialising CR as a minor, non-life-threatening illness promotes the idea that CR does not affect patients significantly. However, CR may result in significant co-morbidity, presenteeism and absenteeism from work and school.
6. Local allergic rhinitis
Recently, local allergic rhinitis (LAR) has been
recognised as a condition.16 In LAR, patients
report typical allergy-induced rhinitic symptoms but all
IgE-based allergy testing is negative. IgE is produced locally
in response to allergens in the nose, but not systemically.16
Only provocation testing diagnoses the problem; however, these
tests are not widely available and only a limited number of
allergens can be tested. However, patients with this condition
do respond to the usual treatments for AR (including
antihistamines and intranasal steroids).
7. Treating CR
Antibiotics must not be used for a ‘cold’.17 Upper respiratory tract infections are usually viral, and antibiotic use in this condition only leads to the evolution of resistant flora.
Previous SAARWG guidelines have discussed the therapeutic modalities for AR in depth.18 , 19 Topical use of corticosteroids remains the drug of choice, although antihistamines appear to be more acceptable for the treatment of young children and are effective. Allergen immunotherapy is an important therapeutic option.
Aspirin-induced respiratory disease is a condition where sensitivity to non-steroidal anti-inflammatory drugs leads to asthma, nasal symptoms and polyposis. Therapy involves specific aspirin desensitisation and avoidance of Cox-I inhibitors. Montelukast is a useful therapeutic option for some patients.20
Therapy of non-allergic, so-called ‘vasomotor’ rhinitis is
difficult. There is no standard therapy which always works. Some
patients respond to intranasal corticosteroids,21 and
other therapies that may work in selected patients are topical
and occasional use of topical decongestants. However, the
benefit of topical decongestants often leads to the overuse of
this form of therapy, which may lead to rebound or rhinitis
8. Surgical intervention for CR
A number of anatomical abnormalities of the nose and sinuses may cause rhinitis symptoms and many may co-exist with AR. Thus at some stage in the medical management and investigation of CR, where therapy is ineffective, the patient should be evaluated for anatomical abnormalities, including septal deviation, nasal polyposis and tumours of the nose and sinuses. Referral to a specialist and radiological imaging may be necessary.
Every patient who experiences chronic snoring must be
investigated for CR and have the condition managed adequately.
If the snoring continues, they should be evaluated and managed
for adenoidal hypertrophy. This is particularly important in
children, who are at risk of developing right-sided heart
failure and cor pulmonale.
9. New international guidelines on CR/AR
Doctors in South Africa have regularly updated AR guidelines
for local application.1
19 The previous revision
of the ARIA guideline has suggested 10 areas that require global
applicability of ARIA and have unmet needs.23 Recent
South African guidelines have addressed some of these issues.
however, some areas, especially for CR, that still require
attention (Table 2).
10. Sport and CR
Competitive sportsmen may experience significant rhinitic symptoms and require that their symptoms be managed.24 A number of reasons for this phenomenon have been proposed.24 Care must be taken with medication because of potential adverse effects and/or ‘anti-doping’ codes. Permitted and banned medications are listed in Table 3.25
11. Doctor and patient education for CR
Patients with CR must be educated about their condition and therapy. Clinical studies indicate that only 31% of patients are regularly shown how to use nasal sprays.26 There is good evidence from international and local studies that patients are frustrated by CR – education helps to allay fears and concerns, and improves medication compliance.26 , 27
Conflict of interest. Aspen HealthCare provided an unrestricted grant for the meeting of the South African Allergic Rhinitis Working Group (SAARWG).
1. Luyt DK, Green RJ, Alright P, et al. Management of allergic rhinitis in South Africa. S Afr Med J 1996;56(10):1315-1328.
2. Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008;38:19-42. [http://dx.doi.org/10.1111/j.1365-2222.2007.02888.x]
3. Bousquet J, Khaltaev N, Cruz AA, et al. ARIA (Allergic Rhinitis and its impact on Asthma (ARIA) 2008 Update. Allergy 2008;63(Suppl 86):8-160. [http://dx.doi.org/10.1111/j.1398-9995.2007.01620.x]
4. Mercer MJ, van der Linde GP, Joubert G. Rhinitis (allergic and nonallergic) in an atopic pediatric referral population in the grasslands of inland South Africa. Ann Allergy Asthma Immunol 2002;89(5):503-12. [http://dx.doi.org/10.1016/S1081-1206(10)62089]
5. Strachan D, Sibbald B, Weiland S, et al. Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: The International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Allergy Immunol 1997;8(4):161-176.
6. Zar HJ, Ehrlich RI, Workman L, Weinberg EG. The changing prevalence of asthma, allergic rhinitis and atopic eczema in African adolescents from 1995 to 2002. Pediatr Allergy Immunol 2007;18(7):560-565. [http://dx.doi.org/10.1111/j.1399-3038.2007.00554.x]
7. Zhang YM, Zhang J, Liu SL, et al. Prevalence and associated risk factors of allergic rhinitis in preschool children in Beijing. Laryngoscope 2013;123(1):28-35. [http://dx.doi.org/10.1002/lary.23573.]
8. Blomme K, Tomassen P, Lapeere H, et al. Prevalence of allergic sensitization versus allergic rhinitis symptoms in an unselected population. Int Arch Allergy Immunol 2012;160(2):200-207. [http://dx.doi.org/10.1159/000339853]
9. Blando J, Bielory L, Nguyen V, Diaz RI, Jeng HA. Anthropogenic climate change and allergic disease. Atmosphere 2012;3(1):200-212. [http://dx.doi.org/10.3390/atmos3010200]
10. Berman D. Climate change and aeroallergens in South Africa. Curr Allergy Clin Immunol 2011;24(2):65-71.
11. Lin G, Zacharek M. Climate change and its impact on allergic rhinitis and other allergic respiratory diseases. Curr Opin Otolaryngol Head Neck Surg 2012;20(3):188-193. [http://dx.doi.org/10.1097/MOO.0b013e3283524b14]
12. Green RJ, Davis G, Price D. Concerns of patients with allergic rhinitis: The Allergic Rhinitis Care Programme in South Africa. Prim Care Respir J 2007;16(5):299-303. [http://dx.doi.org/10.3132/pcrj.2007.00062]
13. Potter PC, Van Niekerk CH, Schoeman HS. Effects of triamcinolone on quality of life in patients with persistent allergic rhinitis. Ann Allergy Asthma Immunol 2003;91(4):368-374. [http://dx.doi.org/10.1016/S1081-1206(10)61684-5]
14. Potter PC, Paediatric Levocetirizine Study Group. Efficacy and safety of levocetirizine on symptoms and health-related quality of life of children with perennial allergic rhinitis: A double-blind, placebo-controlled randomized clinical trial. Ann Allergy Asthma Immunol 2005;95(2):175-180. [http://dx.doi.org/10.1016/S1081-1206(10)61684-5]
15. Green RJ, Luyt DK. Clinical presentation of chronic non-infectious rhinitis in children. S Afr Med J 1997;87(8):987-991.
16. Rondón C, Campo P, Togias A, et al. Local allergic rhinitis: Concept, pathophysiology, and management. J Allergy Clin Immunol 2012;129(6):1460-1467. [http://dx.doi.org/10.1016/j.jaci.2012.02.032]
17. Brink A, Cotton M, Feldman C, et al. Updated guidelines for the management of upper respiratory tract infections in South Africa: 2008. S Afr J Fam Prac 2009;51:105-114.
18. Potter PC, Carte G, Davis G, et al. Clinical management of allergic rhinitis - the Allergy Society of South Africa Consensus update. S Afr Med J 2006;96(12 Pt 2):1269-1272.
19. Green RJ, Hockman M, Friedman R, et al. Allergic rhinitis in South Africa: 2012 guidelines. S Afr Med J 2012;102(8):693-696. [http://dx.doi.org/10.7196/samj.5810]
20. Scow DT, Luttermoser GK, Dickerson KS. Leukotriene inhibitors in the treatment of allergy and asthma. Am Fam Physician 2007;75(1):65-70.
21. Baccioglu Kavut A, Kalpaklıoğlu F. Efficacy and safety of once daily triamcinolone acetonide aqueous nasal spray in adults with non-allergic and allergic rhinitis. Allergol Immunopathol 2012 (Epub ahead of print). [http://dx.doi.org/10.1016/j.aller.2012.05.006].
22. Druce HM, Spector SL, Fireman P, et al. Double-blind study of intranasal ipratropium bromide in nonallergic perennial rhinitis. Ann Allergy 1992;69(1):53-60.
23. Bousquet J, Schünemann HJ, Samolinski B, et al. Allergic Rhinitis and Its impact on Asthma (ARIA): Achievements in 10 years and future needs. J Allergy Clin Immunol 2012;130(5):1049-1062. [http://dx.doi.org/10.1016/j.jaci.2012.07.053]
24. Bonini S, Bonini M, Bousqet J, et al. Rhinitis and asthma in athletes: An ARIA document in collaboration with GA2LEN. Allergy 2006;61(6):681-992. [http://dx.doi.org/10.1111/j.1398-9995.2006.01080.x]
25. The World Anti-doping Agency (WADA). The 2013 prohibited list effective January 1, 2013. Adapted form ARIA guidelines 2006: Athletes. Lausanne, Switzerland: WADA; 2012. http://www.wada-ama.org (accessed 5 May 2013)
26. Blaiss MS, Meltzer EO, Derebery MJ, Boyle JM. Patient and healthcare-provider perspectives on the burden of allergic rhinitis. Allergy Asthma Proc 2007;28 Suppl 1:S4-10. [http://dx.doi.org/10.2500/aap.2007.28.2991]
27. Gani F, Pozzi E, Crivellaro MA, et al. The role of patient training in the management of seasonal rhinitis and asthma: Clinical implications. Allergy 2001;56(1):65-68.
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