Allergic rhinitis and rhinoconjunctivitis — clinical case

Case

A 7-year-old girl presents each spring with paroxysms of sneezing, itchy watery eyes, a constantly blocked nose and night-time mouth breathing that disturbs her sleep. Her teacher reports that her concentration has fallen over the past month. She had eczema in infancy and her father has asthma. [1]

Findings

On examination she rubs her nose upwards repeatedly, producing a transverse nasal crease. Anterior rhinoscopy shows pale, violaceous, boggy inferior turbinates with clear watery rhinorrhoea; she has bilateral conjunctival injection with Dennie-Morgan infraorbital folds and allergic shiners, and cobblestoning of the oropharyngeal mucosa. She is afebrile with no chest signs. The working diagnosis is moderate-to-severe persistent seasonal allergic rhinoconjunctivitis within an atopic phenotype. [12]

Investigations

Skin-prick testing demonstrates a wheal of 5 mm to grass-pollen extract and 4 mm to house-dust-mite extract, both well above the negative control, confirming dual sensitisation. Total serum IgE is mildly elevated. No imaging is required because there is no clinical suspicion of structural disease, chronic rhinosinusitis or complication. [12]

Management

She begins an intranasal corticosteroid — mometasone furoate 50 micrograms, one spray to each nostril daily — as the most effective single therapy for moderate-to-severe persistent disease, together with an oral second-generation antihistamine (cetirizine 5 mg daily) and twice-daily saline nasal irrigation. Allergen-avoidance advice covers pollen avoidance during the season and dust-mite control measures at home. Correct intranasal spray technique is demonstrated, with the nozzle directed away from the nasal septum to minimise epistaxis. [5]

Course

At two-week review her nasal congestion and eye symptoms have improved markedly, her sleep is restored and her school concentration is recovering. She continues intranasal corticosteroid therapy through the pollen season and is reviewed six-monthly. Because she has a strong atopic history and documented sensitisation, she is counselled that allergen immunotherapy may be considered if symptoms remain refractory or to reduce her risk of progressing to asthma. [1]