AAO-HNSF Primary Care Otolaryngology Handbook

ALLERGY

Allergen Avoidance Allergen avoidance is challenging when considering inhalant allergies, since this would require the near impossible act of avoiding environ- mental exposure to the allergen. Efforts can be made to reduce or avoid certain allergens, but these are not considered foolproof. Allergy testing is helpful in determining which allergens should be avoided. For example, patients with a dust mite hypersensitivity can reduce their exposure to mattress and pillow covers, routinely wash linens, avoid carpeted floors or clean carpets routinely, use HEPA filters, keep home humidity low, and apply acaricides. Sensitivity to animal dander can be mitigated by avoiding animals. Pharmacotherapy Pharmacotherapy helpful for allergic symptoms includes oral or topical antihistamines, intranasal steroid (INS) sprays, decongestants, topical nasal cromolyn, antileukotrienes or leukotriene receptor antagonists (LTRAs), and oral steroids. Allergy pharmacotherapy is often started empirically before allergy testing. If symptoms respond well, the medi- cation can be continued without proceeding with allergy testing. Monotherapy with oral antihistamines is effective in patients experi- encing runny nose, sneezing, itching, and ocular symptoms but is not effective in reducing nasal congestion unless combined with an oral decongestant. Second-generation antihistamines, such as loratadine, fexofenadine, and cetirizine, are preferred over first-generation antihis- tamines (e.g., diphenhydramine, chlorpheniramine) because of reduced anticholinergic side effects and longer therapeutic duration. INS sprays are recommended for patients who are having nasal symp- toms significantly affecting their quality of life. Nasal steroid sprays are considered the workhorse monotherapy for patients with allergic rhinitis symptoms and are more effective than oral antihistamines and antileu- kotrienes in controlling nasal symptoms. INS side effects are minimal and include nasal irritation, epistaxis, and headaches. Because INS sprays have very low systemic bioavailability, traditional concerns regarding steroid side effects and growth retardation do not apply. Intranasal anti- histamine sprays can be used alone or in combination with INS sprays to control nasal symptoms in seasonal and perennial allergic patients. These medications have a quicker onset of action than INSs and can be used as needed. They have greater efficacy in controlling nasal congestion than oral antihistamines with fewer side effects.

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