Manifestations of

allergic rhinitis
Dr Paul Carson describes three very different cases of allergic rhinitis
that demonstrate the severe impact it can have on people’s lives

A llergic rhinitis is an ignored, misunderstood,

underdiagnosed and badly treated condition.
Virtually unheard of before 1800, seasonal allergic
apartment to little more than bare boards and a
wooden bed. Her cough continued.
The hospital advised nothing else could be
rhinitis has increased dramatically in prevalence done and suggested to her GP that this was pos-
since 1965. It is considered to affect up to 25% sibly a psychological cough and recommended a
of the Irish population as a whole, and maybe as mild tranquilliser. In desperation (and convinced it
much as 40% of the adolescent and young adult was not a psychological cough) she sought help
population (based on UK statistics). elsewhere. During questioning at a reputable
However, facts and figures do not capture the private allergy clinic she agreed that her nose was
various ways in which the condition takes its toll blocked all the time, that her senses of taste and
on patients’ health. By contrast, real life stories smell were poor and that her hearing was down
highlight the link between allergic rhinitis and a (“I have had to turn up the volume on my iPod
range of interlinking conditions. recently”).
Allergic rhinitis and its link to asthma When examined, she was found to have
Case 1: a 35-year-old publishing editor had severe swelling of her nose lining with dramatic
an intractable cough. She also had asthma polypoid degeneration of the inferior turbinate
and was using standard full strength anti- (see Figure 1). “You’re the first doctor to have
asthma therapy. The cough was socially inspected my nose,” she remarked.
embarrassing and spoiled her quality of life. There was fluid behind both eardrums sug-
Any type of conversation was cut short by a gesting Eustachian tube obstruction. Further
bout of convulsive spluttering. questioning revealed she worked in a smoky
She attended two GPs in the same London office (the non-smoking ban hadn’t come into
practice and the respiratory unit of a top London effect in the UK in small offices) and that the
teaching hospital. There she was reviewed by owner had a large cat that shed hair.
three specialists (one a pulmonary allergist), had It was explained that the cough was almost
multiple tests including chest x-ray, pulmonary certainly due to her aggressive, unrecognised and
function tests and allergy tests. untreated nose and sinus allergy. It was suggested
She showed very large responses to dust that while her home environment might be per-
mites, pollens and cat hair. She was given a fect, her workplace was a definite health hazard.
fact sheet on dust mites and de-cluttered her She was treated appropriately and the nasal cavity

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 Figure 1
stabilised. To say her life changed for the better
is an understatement: symptom scores for her
Gross and severe allergic changes
rhinitis and asthma dropped by 80%. within the nasal cavity: nasal polyps
The cough flared at work and in smoky
environments so she quit her job and found a
better (and safer) office. She is now enjoying a
dramatically improved lifestyle. Her hearing has
improved as well.
If an Oxford-educated (as she is), articulate
and successful publishing executive can have so
much difficulty having her problem identified
and treated, it says a lot about the continuing
ignorance throughout the medical profession
concerning the link between rhinitis and asthma,
and its correct management:
• Allergic rhinitis involves the sinuses as well as
the nose tiredness.
• Allergic rhinitis may cause nose and sinus symp- If the allergic rhino-sinusitis is aggressive, the
toms only child may get intermittent hearing loss; one day
• Allergic rhinitis may provoke chest symptoms being bright and alert in class, interacting and
as well co-operating, the next day seeming distant and
• Allergic rhinitis may co-exist with asthma detached, ignoring questions or not fully grasping
• Allergic rhinitis (untreated) may allow nasal what’s going on. The teachers are at a loss to
polyps develop explain these variations in attentiveness and the
• Coexistent allergic rhinitis in asthmatic children child’s parents can’t quite understand the situa-
causes more asthma-related hospital admissions tion either. It’s not uncommon for these children
and greater total days spent in hospital. to be labelled ‘difficult’.
Allergic irritability syndrome of children Allergic rhino-sinusitis also provokes intense
Allergic nose and sinus problems make people fatigue. If an affected child is not treated, he/she
feel quite miserable. Of that, there is no argu- can miss out on ordinary children’s activities and
ment. However, allergic rhino-sinusitis in children, can be isolated and ignored.
if unrecognised or badly managed, can have a I’ve been talking about this for years to the
significant toll on emotional as well as physical point of being considered a crank. Then an article
wellbeing. appeared that summarised my observations to
For years I’ve been dealing with children a tee: Making the allergic child happy: treating
troubled by multiple allergy problems and I’ve more than symptoms.1
wondered how they get through a full school- The authors of this piece had the scientific
day. What with their itchy eczematous skin, their background to stand over their claims. The term
snuffly and irritable noses and wheezy chests, allergic irritability syndrome has been coined
they carry a significant burden of ill-health. Adults to explain the many unpleasant symptoms and
know how to complain (and rarely hold back), features children with untreated allergic rhino-
whereas some children don’t know any better. allergies may show. So here goes. Children with
They think everyone goes around with a bunged unrecognised (and therefore untreated) ARS:
up nose, wheezy chest and an almost perpetual • Have a significantly impaired quality of life

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 Figure 2
• Have significant learning difficulties
• Have a lower ability to achieve different types of Dramatic allergic challenge in the
knowledge (factual, conceptual and knowledge nasal mucosa of a young boy: severe
application) compared with healthy children allergic rhinitis
• May suffer sleep apnoea, snoring and disturbed
sleep pattern. This in turn leads to daytime
drowsiness, grumpy mood and poor school
performance
• May, in severe cases, have ARS causing or at
least contributing to attention deficit hyperactiv-
ity disorder (ADHD)
• May have impaired hearing if fluid collects in the
inner ear (serous otitis media)
• May suffer repeated ‘head colds’ that go down
to the chest (which is really an untreated nose
and sinus allergy triggering early asthma).
• May have nasal blockage and irritation; dark
circles around the eyes with puffiness of the both parents. “We’re miles away from any horses
lower lids and Jack doesn’t even like going near them.”
• May have poor concentration; disruptive behav- But the family doctor, wise man that he is,
iour and unexplained mood swings. recognises that something has to be irritating
Case 2: Jack, aged ten, is a problematic child Jack’s nose and sinuses. He advises the boy’s par-
at home and at school. He seems constantly ents to check their house carefully for horse hair.
agitated, ill-at-ease with himself and Next day he gets a delighted telephone call.
disruptive. His teachers complain that he’s Jack sleeps in a room on his own. But there is a
troublesome, irritable, cranky and hard to spare bed in that room for the occasional visitor.
handle. When they mention this to his parents The bed was inherited from an elderly uncle and
they hear their own concerns echoed by Jack’s the mattress is stuffed with horse hair. Jack uses
mum and dad. They too find the boy difficult. the bed as a trampoline.
In case there’s a physical cause for his Every time he jumps up and down on it he
behaviour, Jack is brought to the family doctor for disturbs the horse hair which in turn enters his
a check-up. Within the first few minutes of the nose and sinuses which in turn causes havoc with
consultation, the doctor notices how much Jack their delicate membranes. And this is the back-
is agitated by his nose. He’s constantly rubbing at ground allergic challenge to Jack’s ill-health.
it, dragging his sleeve along the nostril openings, Out go the horse hair bed and mattress. Jack’s
snorting and snuffling. room is steam cleaned to remove any residual
When the doctor inspects the inside lining traces of horse hair. Then Jack’s troublesome aller-
of Jack’s nose he realises immediately that the gic sinusitis is successfully treated with medicine.
boy has an aggressive nose and sinus allergy (see The boy improves dramatically. His mood,
Figure 2). personality, temperament and behaviour recover
He arranges for a battery of tests, including to normal limits within a week. Jack’s parents
an allergy screen. Surprisingly, the only abnormal are astonished, Jack’s teachers delighted. Jack’s
reaction to show up is that Jack has a strong horse doctor is pleased as punch at his diagnostic skills,
hair allergy. “That makes no sense,” complain and Jack is a much more contented child. Jack has

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 been suffering from ‘allergic irritability syndrome’. especially, but no domestic pets.
Allergic rhinitis: the epidemic She started working in Ireland in a country
The number of people, especially chil- house in July 2007. The owners kept horses and
dren, troubled with nose and sinus problems went riding daily. They had dogs that more or
has increased over the last decade. In the US, less had the run of the downstairs and cats that
health experts estimate 37 million Americans are sneaked into any room with an open door.
affected by rhino-sinusitis every year. Healthcare Within one month of living and working in
providers report nearly 32 million cases of chronic this environment, Abasiofun developed severe
sinusitis annually. head colds and sneezing attacks. Her employers
Americans spend $5.8 billion each year consoled her that this was just a response to Ire-
on healthcare costs related to nose and sinus land’s cold and damp conditions compared to the
ill-health. The figures for the UK and Ireland sug- hot and dry Nigerian climate. Abasiofun hoped
gest there are approximately 8.5 million sufferers they were right.
spending millions of pounds and euros on nasal But Abasiofun’s head colds got worse and she
relief products. had difficulty sleeping at night. She was notice-
The increase in rhinitis reflects the rise in ably breathless with mild exertion. As the weeks
allergy-related conditions generally and is putting went on, she became wheezy and her breath-
an extra burden on already overstretched health ing was laboured. Her skin, once smooth and
services. Unfortunately, in the UK and Ireland unblemished, was now itchy and irritable. She
there aren’t enough facilities to deal with the was scratching at it, something she’d never done
demand. In Britain this was investigated by a before. By week 12 of living in the country house,
House of Commons committee and their findings Abasiofun was so unwell she went to see the local
make for depressing reading. In short, the Com- doctor. He recognised that the girl had a severe
mittee found a serious epidemic of allergy and the rhinitis that was triggering asthma (see Figure 3).
Department of Health agreed. He also commented she was developing
Allergy care in the NHS was totally inadequate eczema in the areas usually seen in children – the
at all levels with a postcode lottery of premium creases of the knees and elbows. As part of her
care. In Ireland it’s no better, indeed it may be check-up, the doctor ordered allergy tests.
even worse. The more Westernised a society The results showed that Abasiofun was
becomes, the more it produces allergy suffer- severely allergic to horse hair, dust mites and cat
ers. And when healthy, apparently non-allergic hair. Minute particles, smaller than a speck of
individuals move from their low allergy lifestyle to dust, of these allergy-provoking substances had
a high-allergy environment, some begin to suffer. swept inside the girl’s nose and sinuses, triggering
Case 3: Abasiofun, a 24-year-old Nigerian, an aggressive allergic sinusitis. This in turn kick-
who lived in Nigeria all her life and only started asthma and, slowly but gradually, eczema.
moved to Ireland in 2007, began showing Abasiofun quit the country house. In fact, she
symptoms of allergy after one month quit Ireland too and returned to her native Nigeria
working in a country house in Ireland. and better health. Here’s the quandary. Abasiofun
At home in rural Nigeria, her lifestyle was must have been carrying the genetic code for
simple and accommodation basic. She shared a allergy all her life. However, her basic living condi-
concrete brick house under thatched roof with tions and lifestyle in Nigeria did not challenge her
her four siblings and parents. There were no car- immune system and so she stayed well.
pets or curtains and minimal furniture. There were The move to a damp and colder climate
animals in the neighbourhood, cattle and dogs was one shock to her system. An even greater

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 Figure 3

Severely challenged nasal mucosa: Eustachian tube may block. The sufferer will
severe allergic rhinitis with then experience hearing loss or at least reduced
endematous turbinate hearing acuity
• Running along the ‘ceiling’ of the nose is a
delicate nerve ending that transmits taste and
smell to the brain. With persisting swelling of
the nasal lining, this nerve becomes so squeezed
that it begins to lose its function. When this
happens, the first sensation to fade is the sense
of smell. After that, the sense of taste, especially
for spice, becomes impaired. Neglected, both
taste and smell can be lost (but do recover with
the correct treatment)
• Significant post-nasal drip can cause nausea
and decreased appetite. This is an important
factor in children who may be frail and look
undernourished
shock was the amount of high allergy-provoking • There is a nerve link between the nose and eyes
material she suddenly became exposed to. Her such that an irritated nose eventually triggers
allergy cells were challenged in a way they’d never irritable eyes
experienced and Abasiofun started showing all • With significant nasal obstruction, the sufferer
the signs of a highly allergic individual. snores heavily. In severe obstruction, sleep
She first developed sinusitis, then asthma apnoea begins. This applies to children as well
and finally eczema. (Usually, in allergic babies the as adults
allergic events are in the reverse order: ie. eczema, • Sleep apnoea in children causes fatigue, poor
followed by nose and sinus allergy and eventually concentration, mood irritability and behavioural
asthma). disturbance
Varied manifestations • Adults and children with persisting or recurring
These are three different manifestations of nose and sinus problems usually have a worsen-
allergic rhinitis and how they affect three very ing of their symptoms during the change of
different individuals. The full range of conditions seasons – March/April and September/October.
associated with allergic rhino-sinusitis are as The Sept/Oct change causes most problems and
follows: starts with a ‘head cold’ that just won’t go away
• Infected or inflamed sinuses can trigger chest • Sinusitis can be a trigger for migraine attacks.
symptoms such as cough, wheeze and shortness Finally, almost all sinus problems occur
of breath because of obstruction of the tubes connecting
• Almost all asthma starts as an untreated nose the nose to the inside of the sinuses. In aggres-
and sinus irritation sive, allergy-driven sinusitis there is often dramatic
• Almost all asthma involves problems in the nose fluid blistering of the nose lining that further
and sinuses. If the nose and sinus issue is not blocks the sinus openings. Almost all sinus prob-
treated then the patient suffers unnecessary lems can be helped by unblocking these tubes. n
extra discomfort and may have to use more anti- Paul Carson is a GP with an interest in
asthma medication than necessary allergies at the Slievemore Clinic, Stillorgan,
• In aggressive nose and sinus swelling, the Dublin

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